Endoscopic ultrasound (EUS)-assisted transgastric rendezvous procedures have been
carried out in patients with obstructive chronic pancreatitis, occasionally inserting
stents into the main pancreatic duct (MPD) to facilitate drainage [1]
[2]
[3]
[4]
[5]. This is the first known report of duodenal stent placement via transgastric access.
A 62-year-old male with portal hypertension, presented with symptomatic alcohol-induced
chronic calcific pancreatitis and MPD stones. Drainage could not be achieved during
two prior endoscopic retrograde cholangiopancreatographies (ERCPs) due to severe MPD
stricturing and occluding intraductal stones. Use of multiple guide wires and attempted
forced balloon pancreatogram failed to allow access, or even, visualization of the
upstream MPD ([Fig. 1]).
Fig. 1 Initial endoscopic retrograde cholangiopancreatography, attempted balloon pancreatogram,
and attempted wire insertion failed to allow access, or even, visualization of the
upstream main pancreatic duct (MPD).
Linear EUS was then carried out revealing changes compatible with severe calcific
chronic pancreatitis. Initially, a 22 G needle was advanced transgastrically into
the MPD, which measured 7 mm in diameter. A 0.18" guide wire could not be fed through
into the duodenum. Therefore, a 19 G needle was transgastrically inserted and a 0.21"
guide wire was advanced into the duodenum via the minor papilla ([Fig. 2] and [3]). We performed catheter and balloon (4 mm and 6 mm) dilatation of the entire tract
([Fig. 4]). Then a 7 Fr 7 cm straight stent was advanced through the echoendoscope and transgastrically
into the pancreas, and eventually to the border of the minor papilla and duodenum
([Fig. 5]). We failed to initially consider the need to remove the back flange, which we could
not advance through the gastric wall. Therefore, the duodenoscope was reinserted and
a snare was used to retract the stent further into the duodenum ([Fig. 6]). A second 7 Fr 7 cm straight stent was inserted to further promote drainage. No
complications developed and the patient is now asymptomatic 6 weeks following therapy.
This report demonstrates the ability to achieve transpapillary stenting via EUS and
a transgastric approach. It should also serve as a reminder to remove the back flange
to facilitate stent insertion.
Fig. 2 Insertion of a 19 G needle transgastrically into the MPD, which measured 7 mm in diameter.
Fig. 3 Advancement of a 0.21" guide wire into the duodenum via the minor papilla.
Fig. 4 Balloon (4 mm) dilatation of the distal pancreatic duct.
Fig. 5 A 7 Fr 7 cm straight stent was advanced through the echoendoscope and transgastrically
into the pancreas, and eventually to the border of the minor papilla and duodenum.
Fig. 6 Reinsertion of the duodenoscope and use of a snare to retract the stent further into
the duodenum.
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