endoscopic ultrasonography-guided pancreatic duct access: techniques and literature review of...

Review

Endoscopic ultrasonography-guided pancreatic ductaccess: Techniques and literature review ofpancreatography, transmural drainage andrendezvous techniques

Takao Itoi,1 Kazuhiko Kasuya,2 Atsushi Sofuni,1 Fumihide Itokawa,1 Toshio Kurihara,1

Ichiro Yasuda,4 Yousuke Nakai,3 Hiroyuki Isayama3 and Fuminori Moriyasu1

1Department of Gastroenterology and Hepatology, 2Third Department of Surgery, Tokyo Medical University,3Department of Gastroenterology and Hepatology, The University of Tokyo, Tokyo and 4First Department ofInternal Medicine, Gifu University, Gifu, Japan

Endoscopic ultrasonography-guided (EUS)-guided pancreaticinterventions have gained increasing attention. Here we reviewEUS-guided pancreatic duct (PD) access techniques and out-comes. EUS-guided PD intervention is divided into two types,antegrade and rendezvous techniques, following EUS-guidedpancreatography. In the antegrade technique, pancreaticoen-terostomy is carried out by stent placement between the PD andthe stomach, duodenum, or jejunum. Transenteric antegrade PDstenting is conducted by stent placement, advancing anteriorlyinto the PD through the pancreatic tract. The rendezvous tech-nique is carried out by using a guidewire through the papilla oranastomotic site for retrograde stent insertion. In terms of EUS-guided PD stenting, 11 case reports totaling 75 patients (35normal anatomy, 40 altered anatomy) have been published. Thetechnical success rate was greater than 70%. Early adverseevents, including severe hematoma and severe pancreatitis,

occurred in seven (63.6%) of 11 reports. Regarding the rendez-vous technique, 12 case reports totaling 52 patients (22 normalanatomy, 30 altered anatomy) have been published. The techni-cal success rate ranged from 25% to 100%. It was 48% in onereport that involved more than 20 cases. Once stents wereplaced, all patients became free of symptoms. Early mild adverseevents occurred in four (36.4%) of 11 reports. In conclusion,although it can be risky because of possible serious or even fataladverse events, including pancreatic juice leakage, perforationand severe acute pancreatitis, EUS-PD access seems to be prom-ising for treating symptomatic pancreatic diseases caused by PDstricture and pancreaticoenterostomy stricture.

Key words: endoscopic ultrasonography (EUS), EUS-guided pan-creatic duct drainage, interventional EUS

INTRODUCTION

PANCREATIC DUCTAL HYPERTENSION associatedwith several benign and malignant pancreatic condi-

tions, including chronic pancreatitis, pancreatic duct stones,stenotic pancreaticoenterostomy, and intraductal papillarymucinous neoplasms (IPMN) causes pain, which is the mostpredominant symptom in such patients. Both surgical andendoscopic decompression of the pancreatic duct (PD) arecurrently offered to relieve the pain.1,2

Chronic pancreatitis is often seen in the setting of patientswith benign and malignant pancreatic conditions in whichdecompression of the PD is needed. Surgical interventionhas a high success rate (65–85%) in achieving long-termpain relief in such patients, although it has a complicationrate of 6–30%, and a mortality rate of 0–2%.3–11 The successrates of endoscopic intervention vary widely (30–100%).12–19

A recent randomized trial revealed that surgical interventionwas more effective than endoscopic treatment in patientswith only obstruction of the PD due to chronic pancreatitis.3

Nevertheless, endoscopic intervention in selected patients inwhom surgical therapy is refused or impossible for variousreasons, such as severe underlying disease, is still indicatedas an option for PD decompression.

Apart from patients with normal anatomy, stenosis ofthe pancreaticoenterostomy after pancreaticoduodenectomy,

Corresponding: Takao Itoi, Department of Gastroenterology andHepatology, Tokyo Medical University, 6-7-1 Nishi Shinjuku,Shinjuku-ku, Tokyo 160-0023, Japan. Email: [email protected] 2 December 2012; accepted 15 January 2013.

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Digestive Endoscopy 2013; 25: 241–252 doi: 10.1111/den.12048

© 2013 The AuthorsDigestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society

241

which is observed in approximately 30%,20 is the mostcomplex late adverse event.21 In addition to pancreaticoen-terostomy stenosis, pancreatic fistula frequently accompany-ing stenotic pancreaticojejunal anastomosis is also observedin 10–20% of these patients.22–25 Consequently, in 2–3% ofsuch patients, acute recurrent pancreatitis, which requiresfurther treatment, frequently occurs.22,23 Additional surgicalintervention21 is one option and has also been carried out totreat these stenoses. However, in general, surgeons some-times hesitate to carry out additional surgery due to the riskof possible postoperative re-stenosis, postoperative adhe-sions or the additional physical burden on the patients. Thus,several endoscopists have carried out endoscopic treatmentfor such complications caused by surgical interventions.26–28

Apart from patients with normal anatomy, the success rate oftherapeutic endoscopic interventions in patients with priorpancreaticoduodenectomy is not very high26–28 becauseexcessive looping of the endoscope and/or the excessivelength of the afferent limb precludes advancement of theendoscope to the pancreaticojejunal anastomosis, even usinga duodenoscope or long-length colonoscope, and the stenoticpancreatoenteric anastomosis site is not always identified.

Recently, endoscopic ultrasonography-guided (EUS-guided) interventions have become more common.29–54 Ofthese interventions, rendezvous wire passage is used toassist in the cannulation of inaccessible pancreatic ductsthrough not only the major and minor papilla but alsoby pancreaticojejunal anastomosis in prior pancreati-coduodenectomy patients. As an alternative EUS-guidedintervention, EUS-guided pancreatogastrostomy has beencarried out in such patients. Although EUS-guided PDinterventions are useful for salvage therapies in cases ofnon-candidates for surgery and failed endoscopic retro-grade cholangiopancreatography (ERCP), EUS-guided PDaccess is not always successful and often fails even byskilled endosonographers. Therefore, we should considerthe indications and contraindications of EUS-PD access tocarry out these procedures (Table 1).

Here, we review EUS-guided PD access techniques andoutcomes, based on the English language literature.

PROCEDURE PREPARATION

ONE DOSE OF i.v. antibiotics is routinely used prior toEUS-guided PD access. The rationale for antibiotics is

to minimize the risk of peritonitis from leakage of ductal orenteric contents at the transmural puncture site. In additionto no food and drink intake for 1 or 2 days, according to thelaboratory data, we use octreotide (i.m. 100 mL ¥ 2) after theprocedure if needed.

ENDOSCOPE

CURVED LINEAR ARRAY (CLA) echoendoscopes,which have two channel sizes, diagnostic (2.8 mm) and

therapeutic (3.7 or 3.8 mm), are used for the PD puncture.The therapeutic CLA echoendoscope allows passage of a10-Fr stent. The diagnostic CLA echoendoscope enablespassage of a 7-Fr stent. When the rendezvous technique isused, a therapeutic duodenoscope, colonoscope, or single- ordouble-balloon enteroscope is advanced to the papilla orpancreaticojejunal anastomotic site.

EUS-GUIDED PD INTERVENTION

THE PRONE PATIENT position is preferable for EUS-guided PD intervention because of easy determination

of upstream and downstream of the PD by pancreatography.EUS-guided PD intervention is divided into two types, thedrainage and the rendezvous techniques (Table 2). In thedrainage technique, pancreaticoenterostomy is carried out bystent placement between the PD and the gastrointestinal (GItract) (stomach, duodenum, or jejunum). Transenteric ante-grade PD stenting is conducted by stent placement thatis anteriorly advanced into the PD through the tract. In

Table 1 Indications and contraindications of EUS-guided pancreatic duct access

Indications Contraindications

Dilated PD causing ductal hypertension and recurrent pancreatitis Invisible PDInaccessible major and minor papilla by ERCP Non-dilated pancreatic ductInaccessible pancreaticoenterostomotic site Multifocal PD stricturesPresence of PD stricture or disruption Long distance from gastrointestinal tract wall to the PDPresence of stricture of pancreaticoenterostomotic site Intervening large vessel in the puncture routePresence of pancreatic fistula Marked thrombocytopenia (platelet count <50 000/mL)

Anticoagulation therapy

ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasonography; PD, pancreatic duct.

242 T. Itoi et al. Digestive Endoscopy 2013; 25: 241–252


contrast, the rendezvous technique is carried out by using aguidewire across the papilla or anastomotic site for the ret-rograde stent insertion.

EUS-guided pancreatography

TechniqueEUS-guided pancreatography in cases in which endoscopicretrograde pancreatography (ERP) was not successful hadalready been reported in the mid-1990s.29–31 It is a veryimportant technique used together with various interven-tional EUS techniques. As additional procedures, such as therendezvous technique or stenting, are not necessary, it can betransgastrically done using small-caliber 22- and 25-gaugefine-needle aspiration (FNA) needles under ultrasonographicguidance. Interestingly, several endoscopists have describedthe benefits of using a mixture of contrast medium andmethylene blue to easily identify the orifice of the minor ormajor papilla or the anastomotic site in preparation for thefollowing interventional procedures.32,33

Evaluation of the previous dataIn all cases described in previous reports,29–31 EUS-guidedpancreatography was successfully conducted without anyserious adverse events. This may be attributable to the use ofsmall-caliber FNA needles, which make it possible to reducethe leakage of pancreatic juice and procedure-related hem-orrhage and pancreatitis. Lai et al. reported no adverseevents in EUS-guided pancreatic duct aspiration in 12patients with dilated pancreatic ducts.34

LimitationsA long distance between the stomach and pancreas, a fibroticpancreas as in severe chronic pancreatitis, or a non-dilatedPD preclude successful needle puncture into the PD, evenusing small-caliber needles.

EUS-guided PD stenting

Technique

Figure 1 shows endosonography-guided pancreatic ductstenting in a Whipple patient with pancreatic divisum andpancreatic duct stones. Nineteen-gauge needles are prefer-able because the standard 0.035-inch stiff guidewires, whichare provided by several companies, can be inserted into theneedle. We prefer a 0.025-inch guidewire ‘VisiGlide®’ withtip angulation (Olympus Medical Systems, Tokyo Japan)(Fig. 2) because it features a soft, highly flexible tip withoutstanding radiopacity, clear endoscopic visibility, suffi-cient stiffness at the guidewire shaft, a good seeking abilityfor easy therapeutic instrument exchange, and less kinking.53

When EUS-guided PD access is carried out for a dilated PD(>5 mm), 19-guage needles may be suitable to avoid kinkingof the guidewire in the needle, unless the parenchyma of thepancreas is fibrotic. In contrast, if the PD is not dilated or ifthe parenchyma of the pancreas is fibrotic, a 22-gauge needleis preferable because of easy needle puncture. However, a22-gauge needle can only accept 0.018- or 0.020-inchguidewires. The 0.018-inch guidewires lack the stability andtrackability required for over-the-wire intervention. Further-more, fluoroscopic visibility is very poor. Therefore, if0.018- or 0.020-inch guidewires are used as a first wire,replacement with larger caliber and stiffer guidewires is nec-essary. Ideally, the guidewire should be advanced as long aspossible in preparation for the following stenting. In particu-lar, as a stiff guidewire usually has a hydrophilic portion, thestiff portion of the wire is placed in the PD.

Apart from the size of needles, 0.018-, 0.021-, 0.025-,0.032-, and 0.035-inch hydrophilic guidewires with tip angu-lation (Radifocus®; Terumo Co., Tokyo, Japan) are available.They have outstanding seeking ability in the PD for advanc-ing the guidewire to an ideal location upstream or down-stream of the PD and to pass it across the major and minorpapilla or the pancreaticojejunum anastomosis, for example.However, once kinking of the hydrophilic guidewire in theneedle occurs, breaking of the guidewire may follow, result-ing in a residual fragment of the wire remaining in the PD.

Dilation of the needle tract is mandatory prior to stenting.The size of dilation depends on the size of the PD stent.Graduated dilation catheters and balloon catheters can beused for bougienage of the tract. We usually use a taperedinjection catheter (ERCP catheter; MTW Co., Düsseldorf,Germany) (Fig. 3) for the first bougie because it enablessmooth insertion of other devices. Then, 5–7-Fr dilationcatheters (Soehendra Dilation Catheter; Cook Medical,Winston-Salem, NC, USA) are advanced into the PD.Balloon catheters are also used for tract dilation. A 4-mmdilating balloon has a 5 Fr or similar size of tapered catheter.Occasionally, advancement of the dilation catheter orballoon catheter is difficult or impossible because of resis-tance of a rigid tract or difference in direction between theneedle tract axis and the pushing force direction. To facilitate

Table 2 Types of EUS-guided pancreatic duct approach

I. Drainage technique1. Pancreaticoenterostomy

PancreaticogastrostomyPancreaticoduodenostomyPancreaticojejunostomy

2. Transenteric antegrade PD stentingPD stenting across the papillaPD stenting across the gastro-/jejuno-anastomosisPD stenting across the fistula and the papilla or

anastomosisII. Rendezvous technique

1. Retrograde PD stenting across the papilla2. Retrograde PD stenting across the anastomosis

EUS, endoscopic ultrasonography; PD, pancreatic duct.

Digestive Endoscopy 2013; 25: 241–252 EUS-guided pancreatic access 243


a b

c d e

f g

Figure 1 Endoscopic ultrasound (EUS)-guided pancreatic duct stenting in a Whipple patient with pancreatic divisum and pancreaticduct stones. (a) EUS shows a wall-thickened pancreatic duct. (b) A 19-gauge needle was advanced into the pancreatic duct. (c)Pancreatography shows a dilated pancreatic duct and a filling defect in the distal pancreatic duct, suggesting pancreatic duct stones. (d)A 0.025-inch guidewire was advanced into the pancreatic duct across the minor papilla. (e) Bougie was carried out using a 6-Fr electricalcautery catheter (Endo-Flex, Voerde, Germany). (f) Pancreaticogastrostomy was completed using a 7-Fr biliary stent (ThroughPass;Gadelius Medical, Tokyo, Japan). (g) Endoscopic image shows successful placement of stent.



the procedure, ultrasonographic imaging (which depicts thelongitudinal guidewire) and fluoroscopic imaging (whichshows the same scope position as that of the first puncturetime) should be maintained during the procedure. If we failto keep the initial scope position, we should replace it asclose to the initial location as we can. If these bougies fail,

penetration can be facilitated with a diathermy catheter usinga double lumen needle knife catheter (Fig. 4a) or an over-the-wire type catheter (6.5 Fr; Endo-Flex, Voerde, Germany)(Fig. 4b). It should be noted that diathermy catheters causean acute and late ‘burn-effect’ around the tract, leading toserious adverse events including pancreatitis, pancreaticjuice leakage, bleeding, and perforation.

In EUS-guided transenteric PD stenting, a plastic stent(PS) is suitable. In contrast, fully or partially covered self-expandable metallic stents (SEMS) are not used becausethey can cause blockage of side branches of the PD, leadingto obstructive pancreatitis. Uncovered SEMS should beavoided because of possible pancreatic juice leakagebetween the stomach and pancreas. The size of the PSdepends on the size of the tract after dilation. A stent ofsimilar diameter to the dilated tract may be suitable to avoidpancreatic juice leakage along the needle tract and stentmigration. A 5-Fr or 7-Fr PS is usually used for EUS-guidedPD stenting. Although a multi-aperture PS is frequently usedfor the PD to avoid obstruction of PD side branches, inEUS-guided PD stenting, the necessity for a side aperture inthe PS is controversial because it can cause pancreatic juiceleakage when there is some space between the stomach andthe pancreas. Furthermore, various types of PS are availablefor PD stenting. For example, biliary PS are available as PSwithout a side aperture to avoid unexpected pancreatic juiceleakage.

Figure 2 0.025-inch VisiGlide guidewire (Olympus MedicalSystems, Tokyo, Japan).

Figure 3 MTW catheter for bougie (MTW Co., Düsseldorf,Germany).

a

b

Figure 4 Electrical cautery needle for bougie. (a) Standarddouble lumen needle knife (Olympus Medical Systems, Tokyo,Japan). (b) 6-Fr electrical cautery catheter for bougie (Endo-Flex,Voerde, Germany).



There are two types of PS, namely the Tannenbaum typewithout a side aperture and the side flange type with a sideaperture (Amsterdam type). Both types can be used for EUS-guided PD stenting, but because EUS-guided PD drainage isa side-to-side anastomosis, when using the stent with theside flange and side aperture, if the stent is placed at the siteof the side flange, pancreatic juice leakage from the side holeat the stomach side into the peritoneum will likely occur.Some Amsterdam-type stents are removable with a deliverysystem because of the presence of a string between the stentand the delivery system, the so-called ‘all-in-one stent’(Flexima; Boston Scientific Japan, Tokyo, Japan andThroughPass; Gadelius Medical, Tokyo, Japan) (Fig. 5). Ifwe use these, there is the advantage that if the length of thestent is inappropriate at the time of placement of the stent, orstent advancement is impossible across the tract, the stentcan be removed from the scope, leaving the guidewire inplace and a different stent placement or additional tract dila-tion can be carried out. The length of the stent differs, as it isselected based on the length of the PS in the PD. If thisprocedure is done in patients with surgically altered anatomy,such as a Whipple resection, a longer stent is used for place-

ment across the pancreaticojejunostomy. In terms of theproximal length in the stomach, a relatively longer lengthmay be preferable to avoid unexpected migration.

Stent insertion is the biggest hurdle in this procedurebecause it is often difficult or impossible even if tract dilationis successful. In addition, we usually cannot return once stentinsertion fails because the standard PS is separated from thedelivery system. To avoid such an unfortunate event, we mayuse the ‘all-in-one stent’. Whether upstream or downstreamPS placement is carried out depends on the puncture site andpassage of the guidewire across the papilla or anastomoticsite. Long length placement of PS in the PD would be pref-erable to avoid stent migration.

If we think stent insertion is impossible, a 5–8.5-Fr naso-pancreatic duct catheter placement is one of the optionsbecause we can easily go back if the tract dilation is insuf-ficient. If we select nasopancreatic duct catheter placement,the appropriate length of the catheter can be cut by a scissorscatheter for internal drainage on a subsequent day. Other-wise, as a second intervention, tract cannulation is donealongside the nasopancreatic duct catheter and the PS isplaced after removing the nasopancreatic duct catheter.

Evaluation of the previous dataEleven case reports totaling 75 patients have beenpublished35–45 (Table 3). PD stenting was carried out in 40patients with normal anatomy and in 30 patients with alteredanatomy. In all but seven cases, needle puncture was donetransgastrically. Tessier et al.40 reported on transbulbar punc-ture in seven patients with normal anatomy. Most of theendosonographers used 19-gauge needles for the first punc-ture and a dilator catheter and a balloon dilating catheter fortract dilation. Technical success rate was greater than 70%.In two reports that involved more than 10 cases, technicalsuccess rates were 77% and 92%. Once stents were placed,almost all patients became symptom free. Early adverseevents occurred in seven (63.6%) of 11 reports, includingsevere hematoma and severe pancreatitis.

LimitationsPuncture using a 19-gauge needle into the non-dilated PD, along distance between the stomach and the pancreas, or asclerotic pancreas, as in severe chronic pancreatitis, precludethe completion of PS stenting. Furthermore, a failed proce-dure can lead to serious adverse events because of the cre-ation of a large tract.

EUS-guided rendezvous

TechniqueFigures 6 and 7 show the EUS-guided rendezvous techniquein a normal anatomy patient and in a Whipple patient,respectively. Basically, the EUS-guided rendezvous tech-

a

b

Figure 5 Removable plastic biliary stents. (a) Flexima (BostonScientific Japan, Tokyo, Japan). (b) ThroughPass (GadeliusMedical, Tokyo, Japan).



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c.



nique is similar to the EUS-guided PD stenting describedabove. Briefly, PD access is carried out by puncturing trans-gastrically usually, and rarely transduodenally or transjeju-nally, into the main duct using a 19- or 22-gauge needleunder EUS guidance. In the rendezvous technique, as well asin transenteric antegrade PD stenting, selectability of theguidewire is more important than in pancreatoenterostomybecause the guidewire has to be passed across the papilla oranastomotic site. Thus, less kinking and high selectabilityguidewires are ideal. We prefer a 0.025-inch guidewire‘VisiGlide®’ (Olympus Medical Systems) and a 0.032-inchhydrophilic guidewire (Radifocus®; Terumo Co.). VisiGlide®

is stiffer than hydrophilic guidewires and is an idealguidewire for the rendezvous technique because it is the‘all-in-one’ type, but, occasionally, it is difficult to pass thepapilla or anastomosis compared to hydrophilic guidewires.At that time, a hydrophilic guidewire can be used as the firstguidewire, followed by a VisiGlide® using a tapered catheter(ERCP catheter; MTW Co.) as the bougie. When theguidewire does not work well in the needle, a 5-Fr ERCPcatheter is useful for better selectability in the PD. Apart

from the use of a hydrophilic guidewire or a VisiGlide®,looping the guidewire as many times as possible is manda-tory in the duodenum and jejunum to avoid unexpectedguidewire migration during scope exchange.

Afterwards, the CLA echoendoscope is removed, leavingthe looping guidewire in place.A standard therapeutic duode-noscope in patients with normal anatomy or a colonoscopeand balloon enteroscope in patients with surgically alteredanatomy are advanced to the major or minor papilla and theanastomotic site for retrograde intervention. The guidewire isgrasped with a biopsy forceps (Radial Jaw 4, total length224 cm; Boston Scientific Japan) or snare forceps, and it isbrought out of the endoscope using the ‘through-the-scope’technique. Then, retrograde PS stenting is conducted afterdilation of the papilla or anastomotic site using a dilator anddilating balloon. Since, at this time, the guidewire is still inthe tract, standard PD stenting beyond the puncture site isimpossible, unless the stent length in the PD is less than thePD puncture site. At that time, once a double-lumen catheteris advanced into the PD through the papilla or anastomosisover the first guidewire, the second guidewire is advanced to

a b

Figure 6 Endoscopic ultrasound-guidedrendezvous technique in a normalanatomy patient. (a) Needle punctureand guidewire advancement across thepapilla. (b) Once the echoendoscope isremoved, the guidewire is left in place.Then, the duodenoscope is advanced tothe papilla.

a b

Figure 7 Endoscopic ultrasound-guidedrendezvous technique in a Whipplepatient. (a) Needle puncture and guide-wire advancement across the papilla. (b)Once the echoendoscope is removed,the guidewire is left in place. Then, asingle-balloon enteroscope is advancedto the gastrojejunostomy site.



Tab

le4

Out

com

esof

EUS-

guid

edp

ancr

eatic

duc

tre

ndez

vous

Aut

hor

(yea

r)Su

rgic

ally

alte

red

anat

omy

Pun

ctur

ero

ute

Dia

met

erof

PD

(mm

)P

unct

ure

need

le(g

auge

)G

uid

ewir

e(in

ch)

Bat

aille

&D

epre

z(2

002)

46N

orm

alan

atom

yTD

1022

0.01

8M

alle

ryet

al.(

2004

)47N

orm

alan

atom

y(1

),P

D&

PJS

(2),

Rou

x-en

-Y(1

)TG

2.8/

3/4.

5/5

19,2

20.

025,

0.01

8

Will

etal

.(20

05)48

Gas

troj

ejun

osto

my

TG5

190.

035

Keen

anet

al.(

2007

)49N

orm

alan

atom

yTD

519

0.02

5Sa

ftoi

uet

al.(

2007

)50N

orm

alan

atom

yTG

1019

0.03

5W

illet

al.(

2007

)37N

orm

alan

atom

yTG

Dila

ted

‡19

0.03

5Pa

pac

hris

tou

etal

.(20

07)51

Nor

mal

anat

omy,

PD

&PJ

S(1

)TG

2.5

220.

018

Bar

kay

etal

.(20

10)33

Nor

mal

anat

omy

(14)

,PD

&PJ

S(7

)TG

Dila

ted

‡(7

),no

n-d

ilate

d(1

4)19

,22

0.03

5,0.

021,

0.01

8C

oop

eret

al.(

2003

)52N

orm

alan

atom

yTG

1019

0.03

5It

oiet

al.(

2011

)53P

D&

PJS

(2)

TG6/

319

0.02

5Ki

kuya

ma

etal

.(20

11)44

PD

&P

DS

(1),

PD

&PJ

S(3

)TG

5/6/

5/4

190.

035,

0.02

5Ku

riha

raet

al.(

2013

)45N

orm

alan

atom

y(1

),P

D&

PJS

(10)

TG4/

6/7/

5/9/

6/4/

5/3/

4/5

190.

025

Aut

hor

(yea

r)St

ent

Tech

nica

lsuc

cess

(%)

Clin

ical

succ

ess

(%)

Ad

vers

eev

ents

Earl

yLa

te

Bat

aille

&D

epre

z(2

002)

467

FrP

S10

010

0N

one

NA

Mal

lery

etal

.(20

04)47

7Fr

PS

2510

0M

ildp

ancr

eatit

is(2

5%)

NA

Will

etal

.(20

05)48

10Fr

PS

100

100

Non

eN

one

Keen

anet

al.(

2007

)495

FrP

S10

010

0N

one

Non

eSa

ftoi

uet

al.(

2007

)507

FrP

S10

010

0N

one

Non

eW

illet

al.(

2007

)378.

5Fr

or10

FrP

S69

†10

0Pa

in,b

leed

ing,

per

fora

tion†

Non

ePa

pac

hris

tou

etal

.(20

07)51

NA

100

NA

NA

NA

Bar

kay

etal

.(20

10)33

NA

48N

APa

ncre

atiti

s(m

ild1)

,p

erip

ancr

eatic

absc

ess

(1)

Non

e

Coo

per

etal

.(20

03)52

7Fr

PS

100

100

Non

eN

AIt

oiet

al.(

2011

)537

FrP

S10

010

0Pa

ncre

atic

juic

ele

akag

e(m

ild1)

Non

eKi

kuya

ma

etal

.(20

11)44

5Fr

or7

FrP

S10

010

0N

one

Non

eKu

riha

raet

al.(

2013

)457

FrP

S10

010

0Pa

ncre

atic

juic

ele

akag

e(m

ild1)

,an

eury

smN

one

† 13ca

ses

atte

mp

ted

incl

udin

g5

succ

essf

ulp

ancr

eatic

ogas

tros

tom

ies

and

4su

cces

sful

rend

ezvo

usca

ses

whi

chto

tale

d9

(69%

)suc

cess

fulc

ases

.‡ d

ilate

d,d

ata

unkn

own.

AR

P,ac

ute

recu

rren

tp

ancr

eatit

is;

CP,

chro

nic

pan

crea

titis

;d

ivis

um,

pan

crea

ticd

ivis

um;

GI,

gast

roin

test

inal

;IP

MN

,in

trad

ucta

lpap

illar

ym

ucin

ous

neop

lasm

s;N

A,

not

avai

lab

le;

PD

,p

ancr

eatic

duc

t;P

D&

PG

S,p

ancr

eato

duo

den

ecto

my

plu

sp

ancr

eato

gast

rost

omy;

PD

&PJ

S,p

ancr

eato

duo

den

ecto

my

plu

sp

ancr

eato

jeju

nost

omy;

PS,

pla

stic

sten

t;TD

,tra

nsd

uod

enal

;TG

,tra

nsga

stri

c.



the tail of the PD. Another technique is to advance a single-lumen catheter into the PD near the side of the PD puncturesite and then remove the guidewire, leaving the catheter inplace, and finally re-insert the soft tip of the guidewire intothe catheter to the tail of the PD.

Evaluation of the previous dataTwelve case reports totaling 52 patients have beenpublished33,37,44,46–53 (Table 4). PD stenting was done in 22patients with normal anatomy and in 30 patients with alteredanatomy. In all but two cases reported by Bataille andDeprez46 and Keenan et al.,49 needle puncture was carriedout transgastrically. Most of the endosonographers used19-gauge needles. Various sized PS, ranging from 5 to 10 Fr,were placed across the papilla or anastomotic site. The tech-nical success rate ranged from 25% to 100%. In one reportwhich involved more than 20 cases, the technical successrate was 48%. Once stents were placed, all patients becamefree of symptoms. Early adverse events occurred in four(36%) of 11 reports. However, there were no serious adverseevents, in contrast to EUS-guided PD stenting.

LimitationsPuncture using a 19-gauge needle into the non-dilated PD, along distance between the stomach and pancreas, or a scle-rotic pancreas, as in severe chronic pancreatitis, preclude PDpuncture. Even if PD puncture can be carried out, thepassage of a guidewire across the papilla or anastomotic siteis not always successful. Furthermore, if the guidewire isadvanced across the papilla or anastomotic site, it is oftendifficult to complete the procedure because grasping theguidewire by using an exchanged endoscope is not alwayspossible.

CONCLUSION

EUS-PD ACCESS APPEARS to be promising for symp-tomatic pancreatic diseases caused by PD stricture and

pancreaticoenterostomy stricture. However, it can be riskybecause of possible serious or even fatal adverse events,including pancreatic juice leakage, perforation and severeacute pancreatitis. Nevertheless, we believe that it should beseriously considered in selected patients in whom surgicalinterventions are not appropriate or impossible. For thepurpose of safe and reliable EUS-PD access, development ofdedicated devices is mandatory.

ACKNOWLEDGMENT

WE ARE INDEBTED to Professor J. Patrick Barron,Chairman of the Department of International Medical

Communications of Tokyo Medical University for editorialreview of the English manuscript.

CONFLICT OF INTERESTS

DR T. ITOI gives lectures and consults for OlympusMedical Systems. The other authors declare no conflict

of interests for this article.

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