Pancreatic duct stenting using an endoscopic ultrasound-guided intrapancreatic duct rendezvous technique

A patient was admitted for pancreatic stenting for pancreatic duct stricture due to chronic pancreatitis. However, transpapillary stenting failed because a guidewire could not pass the severe stricture in the pancreatic head. Therefore, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) was conducted by puncture from the stomach, and a plastic stent was placed on the caudal side of the stricture [1] [2]. Following EUS-PD fistula creation, the pancreatic duct was cannulated through the fistula ([Fig. 1 a]), and the guidewire passed through the stricture and was placed in the duodenum via the minor papilla ([Fig. 1 b]). The endoscope was withdrawn leaving the guidewire in place, followed by duodenoscope insertion into the duodenum. Pancreatic duct cannulation and endoscopic pancreatic sphincterotomy were performed using a rendezvous technique [3]; however, the cannula and dilators could not pass the stricture. Therefore, we again switched to the procedure via the EUS-PD fistula, and a 7-Fr stent retriever allowed the breakthrough of the stricture [4] ([Fig. 2a]), followed by dilation of the stricture with a 6-mm balloon catheter ([Fig. 2b]). However, the plastic stent (7 Fr; SUZAKU, Kaneka Medics, Tokyo, Japan) could only be inserted to the midpoint of the stricture ([Fig. 3]). Therefore, the pancreatic duct was cannulated via the minor papilla, and the guidewire was inserted into the stent lumen ([Fig. 4]). Subsequently, a thin-tipped balloon catheter (4 mm; REN; Kaneka Medics) was inserted into the stent over the guidewire, and the balloon was inflated. Finally, the balloon catheter was pulled, and the stent was successfully placed across the minor papilla ([Fig. 5a,b]).

Fig. 1 Guidewire placement. a The pancreatic duct was cannulated through the fistula created via the endoscopic ultrasound-guided pancreatic duct drainage. b The guidewire passed through the pancreatic duct stricture and was placed in the duodenum via the minor papilla.

Fig. 2 The pancreatic stricture was dilated using the dilators via the fistula of endoscopic ultrasound-guided pancreatic duct drainage. a 7-Fr stent retriever. b 6-mm balloon catheter.

Fig. 3 The plastic stent could only be inserted halfway through the stricture and could not be placed across the minor papilla.

Fig. 4 The pancreatic duct was cannulated via the minor papilla, and the guidewire was inserted into the stent lumen, which was placed via the fistula in an antegrade manner.

Fig. 5 The plastic stent was successfully placed across the minor papilla by pulling the balloon catheter inflated within the stent. a Fluoroscopic view. b Endoscopic view.

Stent insertion might fail owing to difficulty in advancing the stent through a severe stricture in EUS-guided antegrade stenting [5]. In such a situation, the abovementioned intrapancreatic duct rendezvous technique can be useful ([Video 1]).

Video 1 Pancreatic duct stenting using an endoscopic ultrasound-guided intrapancreatic duct rendezvous technique.

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• References

• 1 François E, Kahaleh M, Giovannini M. et al. EUS-guided pancreaticogastrostomy. Gastrointest Endosc 2016; 56: 128-133
• 2 Itoi T, Sofuni A, Tsuchiya T. et al. Initial evaluation of a new plastic pancreatic duct stent for endoscopic ultrasonography-guided placement. Endoscopy 2015; 47: 462-465
• 3 Bataille L, Deprez P. A new application for therapeutic EUS: main pancreatic duct drainage with a “pancreatic rendezvous technique”. Gastrointest Endosc 2002; 55: 740-743
• 4 Baron TH, Morgan DE. Dilation of a difficult benign pancreatic duct stricture using the Soehendra stent extractor. Gastrointest Endosc 1997; 46: 178-180
• 5 Itoi T, Kasuya K, Sofuni A. et al. Endoscopic ultrasonography-guided pancreatic duct access: techniques and literature review of pancreatography, transmural drainage and rendezvous techniques. Dig Endosc 2013; 25: 241-252