Endoscopic retrograde pancreatography (ERCP) has become a standard approach to
the treatment and evaluation of chronic pancreatitis [1]
[2]. When anatomical variations and previous surgical interventions preclude the
use of ERCP, antegrade cannulation of the pancreatic duct using endoscopic ultrasound
(EUS) can be performed [3]
[4]. We present a case of EUS-assisted antegrade cannulation of the pancreatic duct
which facilitated the placement of a transpapillary stent.
A 57-year-old man was referred for evaluation of obscure, gastrointestinal bleeding
associated with acute, recurrent pancreatitis. Colonoscopy and upper endoscopy
were unremarkable. EUS examination revealed evidence for chronic pancreatitis.
Also visualized by EUS was a pseudoaneurysm of the gastroduodenal artery which
was compressing the ventral pancreatic duct. The patient was referred for interventional
radiology and the pseudoaneurysm was embolized using coils.
Two months later, the patient showed no further signs of gastrointestinal bleeding.
However, he continued to have episodes of acute pancreatitis. ERCP revealed a
stricture of the ventral pancreatic duct with proximal ductal dilatation (Figure
[1 ]
a). Despite multiple attempts, deep cannulation of the pancreatic duct failed.
Subsequently, a linear EUS scope was introduced into the stomach and a 19-gauge
Echotip needle (Wilson-Cook, Winston-Salem, North Carolina, USA) was inserted
through the stomach and into the pancreatic duct. A 0.035″ Jagwire (Boston Scientific,
Natick, Massachusetts, USA) was deployed antegradely into the pancreatic duct,
past the ampulla, and into the duodenum (Figure [1 ]
b). The EUS scope and needle were then removed, leaving the wire in place. The
wire was then snared in a rendezvous fashion by duodenoscopy (Figure [2]). Using the wire in place, a 5 Fr by 7 cm pancreatic stent was deployed retrogradely
across the ampulla. The patient was discharged home, with no further episodes
of pancreatitis or bleeding having occurred up to 1 year later.
Figure 1 Fluoroscopic images of the pancreatic duct. a Endoscopic retrograde cholangiopancreatography (ERCP) reveals a distal stricture
of the pancreatic duct with mild ductal dilatation proximally. Coils from prior
embolization can clearly be seen. b An endoscopic ultrasound (EUS) scope is shown with a wire passing antegradely,
through the pancreatic duct, and into the duodenum.
Figure 2 An endoscopic view from the second portion of the duodenum. A wire is seen coming
out of the papilla, and a snare is ready to retrieve the wire in a rendezvous
fashion.
In this case, successful placement of a transpapillary stent using EUS and a rendezvous
technique was performed, resulting in a good clinical outcome. To our knowledge,
this is the first report of transpapillary stent placement via this approach.
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