endoscopic ultrasonography-guided pancreatic duct drainage after failed endoscopic retrograde...

Biliary Stenting for Unresectable Malignant Biliary Obstruction

Endoscopic ultrasonography-guided pancreatic ductdrainage after failed endoscopic retrogradecholangiopancreatography in patients with malignantand benign pancreatic duct obstructions

Toshio Kurihara, Takao Itoi, Atsushi Sofuni, Fumihide Itokawa and Fuminori Moriyasu

Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan

Background: Endoscopic ultrasonography (EUS)-guided pan-creatic drainage has been advocated as a rescue treatmentfor management of patients in whom retrograde access to thepancreatic duct (PD) is technically unsuccessful. The aim ofthe present study was to evaluate the feasibility and efficacyof EUS-guided drainage for failed endoscopic retrogradecholangiopancreatography.

Patients and Methods: A total of 17 EUS-guided PD drainage(EUS-PD) procedures were carried out in 14 patients (age: mean64.6 years, range 54–81 years, eight men).

Results: The rendezvous technique was successful in 11 of 17procedures (64.7%). Three of five patients with an unsuccessfulrendezvous technique successfully underwent EUS-PD stenting(7-Fr plastic stent [two cases], 5-Fr endoscopic nasobiliary

drainage [one case]). In the two remaining patients, puncture andpancreatography were successful; however, antegrade passageof the guidewire failed.

Conclusion: EUS-guided decompression of PD is a feasible andeffective treatment for the management of symptomatic high-pressure PD due to stricture of the PD and/or stenotic pancreato-digestive anastomosis. However, this procedure is technicallychallenging, has a high rate of complications, and should be doneonly at tertiary-care centers.

Key words: endoscopic retrograde cholangiopancreatography(ERCP), endoscopic ultrasonography (EUS), endoscopicultrasonography-guided pancreatic duct drainage (EUS-PD), pan-creatic duct (PD)

INTRODUCTION

PATIENTS WITH RECURRENT acute pancreatitis andepigastric pain as a result of pancreatic duct (PD) stric-

ture or stenotic pancreatodigestive anastomosis require treat-ment for ductal decompression. Conventional retrograde PDdecompression such as pancreatic sphincterotomy, pancre-atic stenting, and dilation of PD stricture is a highly effectivetreatment for these patients. However, conventional endo-scopic retrograde cholangiopancreatography (ERCP) issometimes technically unsuccessful as a result of difficultcannulation or strong PD stricture, or because there is nopossible approach to the major papilla, for example, strictureof the duodenum. Furthermore, among patients who undergopancreatoduodenectomy, approach to the pancreatic duct

from the digestive tract side is technically difficult and some-times impossible. This is because of the presence of intesti-nal adhesion and a long tortuous afferent limb that preventsadvancement of the endoscope to the anastomosis. Even ifthe anastomotic site is reached, identification of the stenoticpancreatic anastomosis and PD cannulation is also difficult.Failed drainage under conventional ERCP is a seriousproblem. Percutaneous external or internal drainage or sur-gical procedures have also been carried out to treat thesepatients. However, these procedures have some risk and theirresolution takes time. Recently, endoscopic ultrasonography(EUS)-guided PD drainage (EUS-PD) has been described asa rescue technique for the management of patients in whomERCP is unsuccessful. In the present study, we evaluated thefeasibility and safety of EUS-PD.

METHODS

Patients

FROM FEBRUARY 2010 through April 2012, 14 con-secutive patients with relapsed symptomatic pancreatitis

Corresponding: Toshio Kurihara, Department of Gastroenterologyand Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku,Shinjuku-ku, Tokyo 160-0023, Japan. Email: [email protected] 1 December 2012; accepted 7 February 2013.

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Digestive Endoscopy 2013; 25 (Suppl. 2): 109–116 doi: 10.1111/den.12100

© 2013 The AuthorsDigestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society

109

or epigastric pain as a result of PD stricture, disrupted ductor stenotic pancreatodigestive anastomosis after pancre-atoduodenectomy underwent EUS-PD at Tokyo MedicalUniversity Hospital and Shizuoka General Hospital. A totalof 17 procedures were carried out (Table 1). There were oneand two patients with stricture of PD due to pancreaticcancer and chronic pancreatitis, respectively. The remaining11 patients showed stenotic pancreatodigestive anastomosisafter pancreatoduodenectomy. Pancreatogastrostomy andpancreatojejunostomy (Whipple procedure) had been previ-ously carried out in patients 1 and 10, respectively. In these11 patients, pancreatoduodenectomy was done for variousreasons, including chronic pancreatitis, pancreatic cancer,and intraductal papillary mucinous neoplasm of the pan-creas. All patients underwent conservative therapy and con-ventional ERCP had already been attempted. After failure ofERCP and after obtaining written informed consent, wecarried out EUS-PD decompression.

EUS-guided pancreatic ductdrainage techniquesEndoscopic ultrasonography-guided techniques for PDdrainage are classified into two types, the EUS-guided ren-dezvous technique and EUS-guided PD stenting (via thestomach, pancreatogastrostomy, or the duodenum, pancre-atoduodenostomy). Basically, we attempted the EUS-guidedrendezvous technique first, and if that was not possiblebecause the guidewire could not be passed antegrade acrossthe stricture of the PD or because of stenotic pancreatodi-gestive anastomosis, we carried out EUS-guided translumi-nal drainage.

A dilated pancreatic duct was clearly confirmed by com-puted tomography (CT) or magnetic resonance cholangio-pancreatography (MRCP). We routinely gave i.v. antibioticsprior to EUS-PD access for 2 days. The rationale for antibi-otic use was to minimize the risk of peritonitis from leakageof ductal or enteric contents at the transmural puncture site.In addition to permitting no solid or liquid intake for 1 or 2days, depending on laboratory data, we used octreotide (i.m.,100 mL ¥ 2) after the procedure when needed.

EUS-guided rendezvous techniqueThe EUS-guided rendezvous technique is shown in Figure 1.A therapeutic curved linear array echoendoscope is posi-tioned in the stomach or duodenum. After excluding theblood vessels by using Doppler ultrasonography (US), themain PD was punctured transluminally by a 19-guage or a22-guage fine-needle aspiration (FNA) needle under EUSguidance. PD access was confirmed by EUS imaging andfluoroscopy. Contrast agent was injected via the sheath cath-eter of a FNA needle in order to obtain pancreatography for

the passage of the guidewire and PD stenting. A 0.025-inchguidewire (VisiGlide®; Olympus, Tokyo, Japan) wasinserted into the main PD and passed antegradely across themajor papilla or stenotic pancreatodigestive anastomosis.Looping the guidewire is mandatory, to the maximumdegree, in the duodenum and jejunum to avoid unexpectedguidewire migration during scope exchange. The echoendo-scope was removed, and the guidewire was left in place. Theendoscope was then advanced to the major papilla or pan-creatodigestive anastomosis site. Depending on the specificsituation, a standard therapeutic duodenal endoscope (TJF-260V; Olympus) was selected for patients with normalanatomy, and a colonoscope and a single-balloon endoscope(Olympus) were selected for patients with surgically alteredanatomy. The tip of the guidewire could be detected onendoscopic view, grasped with a biopsy forceps (Radial Jaw4, total length 224 cm; Boston Scientific Japan, Tokyo,Japan), and pulled out through the working channel. Thestricture of the PD or the stenotic pancreatodigestive anas-tomosis was dilated by a tapered ERCP catheter (MTWERCP-catheter; Düsseldorf, Germany), dilation catheter(7-Fr, Soehendra dilation catheter; Cook Medical, Winston-Salem, NC, USA) and a 4-mm-diameter balloon catheter(Hurricane; Boston Scientific, Natick, MA, USA) over theguidewire. Finally, a pancreatic stent (Geenen pancreaticstent; Cook Medical) of appropriate length was retrogradelyinserted in the PD.

EUS-guided PD stentingThe EUS-guided PD stenting technique is shown in Figure 2.It is preferable to advance the guidewire downstream to thepapilla or anastomotic site as far as possible for the followingstenting. If this positioning of the guidewire cannot beaccomplished, then the guidewire is inserted retrogradely tothe pancreatic tail portion. When a guidewire is advanced ineither way, as the stiff guidewire usually has a hydrophilicportion, the stiff portion of the wire must be placed in thePD. Graduated dilation catheters and balloon catheters canbe used for bougienage of the puncture tract. If these funda-mental bougies fail, penetration can be facilitated with adiathermy catheter using a double-lumen needle knife cath-eter or over-the-wire-type catheter (6.5 Fr; Endoflex, Voerde,Germany). After dilation, a 7-Fr plastic stent (Flexima;Boston Scientific Japan and Gadelius Medical, Tokyo,Japan) of appropriate length was placed into the PDtransgastrically.

Stent management is carried out differently depending onthe situation. In patients who had undergone the Whippleprocedure or the rendezvous technique, the plastic stent (PS)was removed within approximately 2 months, preventingstent occlusion and migration, because exchange of the PS isanatomically difficult. In patients with normal anatomy, weplanned exchange of the PS regularly. In patients who hadundergone EUS-PD stenting, the PS was left in place for a

110 T. Kurihara et al. Digestive Endoscopy 2013; 25 (Suppl. 2): 109–116


Tab

le1

Cha

ract

eris

tics

and

outc

omes

ofp

atie

nts

who

und

erw

ent

EUS-

PD

Cas

eno

.A

ge/

Sex

Ind

icat

ion

Ana

tom

yD

iam

eter

ofP

D(m

m)

Pun

ctur

ene

edle

(G)

EUS

tech

niq

ueSt

ent

pla

cem

ent

Sten

tTe

chni

cal

succ

ess

Clin

ical

succ

ess

Ad

vers

eev

ent

Rei

nter

vent

ion

154

/MA

RP

PD

&PJ

S4

19R

end

ezvo

usR

etro

grad

eP

Dst

entin

gac

ross

the

anas

tom

osis

7-Fr

PS

Yes

Yes

No

NA

281

/MA

RP

Nor

mal

anat

omy

619

Ren

dez

vous

Ret

rogr

ade

PD

sten

ting

acro

ssth

ean

asto

mos

is7-

FrP

SYe

sYe

sA

neur

ysm

,p

seud

ocys

tN

A

366

/MA

RP

PD

&PJ

S7

19R

end

ezvo

usR

etro

grad

eP

Dst

entin

gac

ross

the

anas

tom

osis

7-Fr

PS

Yes

Yes

No

NA

468

/FA

bd

omin

alp

ain

PD

&P

GS

222

Panc

reat

ogra

mN

AN

AN

oN

AN

oYe

s

568

/FA

bd

omin

alp

ain

PD

&P

GS

619

EUS-

PD

sten

ting

Tran

sgas

tric

PD

sten

ting

7-Fr

PS

Yes

Yes

No

NA

680

/MA

RP

PD

&PJ

S5

19R

end

ezvo

usR

etro

grad

eP

Dst

entin

gac

ross

the

anas

tom

osis

7-Fr

PS

Yes

Yes

No

Yes

780

/MA

RP

PD

&PJ

S9

19R

end

ezvo

usR

etro

grad

eP

Dst

entin

gac

ross

the

anas

tom

osis

8-m

mSE

MS

Yes

Yes

No

NA

863

/FA

RP

PD

&PJ

S3

19EU

S-P

Dst

entin

gTr

ansg

astr

icP

Dst

entin

gac

ross

fistu

laan

dan

asto

mos

is

5-Fr

NP

DYe

sYe

sN

oYe

s

963

/FA

RP

PD

&PJ

S3

NA

EUS-

PD

sten

ting

Ant

egra

de

PD

sten

ting

acro

ssth

ean

asto

mos

is7-

FrP

SYe

sYe

sN

oN

A

1072

/MA

RP

PD

&PJ

S6

19R

end

ezvo

usR

etro

grad

eP

Dst

entin

gac

ross

the

anas

tom

osis

7-Fr

PS

Yes

Yes

No

NA

1168

/MA

RP

PD

&PJ

S2

22Pa

ncre

atog

ram

NA

NA

No

No

No

NA

1273

/FA

RP

PD

&PJ

S4

19R

end

ezvo

usR

etro

grad

eP

Dst

entin

gac

ross

the

anas

tom

osis

7-Fr

PS

Yes

Yes

No

NA

1366

/FA

RP

PD

&PJ

S5

19R

end

ezvo

usR

etro

grad

eP

Dst

entin

gac

ross

the

anas

tom

osis

7-Fr

PS

Yes

Yes

No

NA

1474

/FC

P,P

FN

orm

alan

atom

y10

19EU

S-P

Dst

entin

gTr

ansg

astr

icP

Dst

entin

g7-

FrP

SYe

sYe

sN

oN

A

1562

/MA

RP

Nor

mal

anat

omy

319

Ren

dez

vous

Ret

rogr

ade

PD

sten

ting

acro

ssth

ep

apill

a7-

FrP

SYe

sYe

sN

oN

A

1661

/FA

RP

PD

&PJ

S4

19R

end

ezvo

usR

etro

grad

eP

Dst

entin

gac

ross

the

anas

tom

osis

7-Fr

PS

Yes

Yes

No

NA

1758

/MA

RP

PD

&PJ

S5

19R

end

ezvo

usR

etro

grad

eP

Dst

entin

gac

ross

the

anas

tom

osis

7-Fr

PS

Yes

Yes

No

NA

AR

P,ac

ute

recu

rren

tp

ancr

eatit

is;

CP,

chro

nic

pan

crea

titis

;EU

S-P

D,

end

osco

pic

ultr

ason

ogra

phy

-gui

ded

pan

crea

ticd

uct

dra

inag

e;N

A,

not

avai

lab

le;

NP

D,

naso

pan

crea

ticd

uct

dra

inag

e;P

D&

PG

S,p

ancr

e-at

oduo

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;

PD

,pan

crea

ticd

uct;

PF,

pan

crea

ticfis

tula

;PS,

pla

stic

sten

t;SE

MS,

self-

exp

and

able

met

allic

sten

t.

Digestive Endoscopy 2013; 25 (Suppl. 2): 109–116 EUS-guided pancreatic duct drainage 111


long period in anticipation of mature fistula formation. Whena patient had recurrent abdominal pain or acute pancreatitisduring the follow-up period, initially conservative therapywas provided. Then, if exchange of the PS was possible, weattempted exchange of the PS. If we were unable to do that,EUS-guided PD drainage was planned again.

RESULTS

A total of 17 EUS-guided PD drainage procedures werecarried out in 14 patients (age: mean 64.6 years, range 54–81years, eight men). These procedures were done at TokyoMedical University Hospital and Shizuoka General Hospitalfrom February 2010 to April 2012. Patient demographics,reconstruction methods after pancreatoduodenectomy, indi-cations, diameters of pancreatic ducts, technical and clinicalsuccess, and complications are summarized in Table 1. Stentplacement using the EUS-guided rendezvous technique wasattempted in all cases. The rendezvous technique was suc-

cessful in 11 of 17 procedures (64.7%), but three patientswith unsuccessful guidewire passage antegrade from themain pancreatic duct across a stenotic pancreatodigestiveanastomosis or duodenal papilla underwent EUS-PD stent-ing. Two of 17 (11.8%) puncture and pancreatogram proce-dures were successful, but, of the antegrade passage of theguidewire, one complication (6.8%) relating to EUS-guidedPD puncture occurred.

EUS-guided rendezvous techniqueA total of 11 EUS-guided rendezvous techniques for decom-pression of PD were carried out in 10 patients (Table 1). Ofthese, eight patients had surgically altered anatomy after theWhipple procedure and two other patients had normalanatomy. Cases 6 and 7 had reintervention for acute recur-rent pancreatitis after stent removal. This patient received anuncovered self-expanding metallic stent (SEMS) (Zilver;Cook Endoscopy, Winston-Salem, NC, USA) across therecurrent stenotic pancreatojejunum anastomosis at reinter-

A B C

D E F

Figure 1 Endoscopic ultrasonography (EUS)-guided rendezvous technique for patients with failed conventional endoscopic retrogradecholangiopancreatography (ERCP). (A) EUS-guided transgastric puncture into a dilated pancreatic duct (PD). (B) Fluoroscopic imagedemonstrates a transgastric pancreatogram. (C) A guidewire is inserted via the sheath of a 19-guage fine-needle aspiration needle andpassed across the pancreatojejunal anastomosis. (D) A guidewire is retrieved with biopsy forceps at a single balloon endoscopy. (E)Fluoroscopic image shows the stenotic anastomosis being dilated by a balloon catheter 4 mm in diameter. (F) Fluoroscopic image showsa 7-Fr stent being placed across the stenotic anastomosis.



vention because the stricture was due to a recurrence ofpancreatic cancer. As a result of the placement of the uncov-ered SEMS, there was no acute recurrent pancreatitis untildeath. We encountered one complication after the EUS-guided rendezvous technique. This patient (case 2) had pan-creatic head cancer and acute recurrent pancreatitis causedby stricture of the main PD (Fig. 3A–C). Two days after theEUS-guided rendezvous technique, the patient reportedabdominal pain and laboratory data showed inflammationand elevated amylase levels. Abdominal CT revealed a pan-creatic pseudocyst with an aneurysm of the splenic artery(Fig. 3D). The patient recovered through treatment by selec-tive angiography and embolization of the aneurysm toprevent rupture of the aneurysm (Fig. 3E,F).

EUS-guided PD stentingA total of four EUS-guided PD stentings were carried outin three patients (Table 1). Two of the three patients had

surgically altered anatomy. Two of the three patientsreceived transgastric PD stenting using 7-Fr plastic stents.The remaining patient (case 8,9) was given a 5-Fr naso-pancreatic duct catheter because sufficient dilation of theneedle tract was difficult due to hardness of the paren-chyma of the pancreas. Twelve days after placement of the5-Fr nasopancreatic catheter, anticipating a mature fistulaformation, a stiff-type guidewire was inserted into thenasopancreatic duct catheter. A lateral-view endoscope wasthen advanced into the stomach and the nasopancreaticcatheter was brought out of the endoscope under fluoro-scopic guidance. After removing the nasopancreatic ductcatheter, we exchanged a stiff guidewire for the hydrophilicwire for passing the stenotic anastomosis. After success-fully passing the guidewire across the stenotic anastomosis,a 7-Fr PS (Flexima; Boston Scientific, Tokyo, Japan) wasinserted into the PD via the fistula antegradely across thestenotic anastomosis.

A B C

D E

Figure 2 Endoscopic ultrasonography (EUS)-guided pancreatic duct (PD) stenting for patients with failed conventional endoscopicretrograde cholangiopancreatography (ERCP) and EUS-guided rendezvous technique. (A) Fluoroscopic image demonstrates a transgas-tric pancreatogram. (B) A guidewire is inserted via the sheath of a 19-guage fine-needle aspiration needle and cannot be passed acrossthe stenotic pancreatojejunal anastomosis. Thus, the guidewire is inserted downstream to the anastomostic site as far as possible for thefollowing stenting. (C) A needle tract is dilated by an ERCP catheter. (D) A needle tract is dilated by a balloon catheter 4 mm in diameter.(E) Endoscopic view shows a 7-Fr plastic stent (Flexima; Boston Scientific Japan, Tokyo, Japan) of appropriate length placed into a PDtransgastrically.



DISCUSSION

WE SET OUT to determine the most appropriate PDdecompression method using endoscopic treatment

for patients with pancreatic ductal hypertension-relatedbenign and malignant PD stricture and stenotic pancreatodi-gestive anastomosis.1–3 In patients with chronic pancreatitiswith PD stricture, in a prospective randomized controlledtrial, surgical drainage of the pancreatic duct was shown to bemore effective than endoscopic treatment.4 However, surgicaldrainage is more invasive than endoscopic treatment and it isnot recommended for patients in a severely ill condition.Therefore, endoscopic treatment in patients with chronicpancreatitis is essential. The standard endoscopic treatmentfor decompression of the PD is to cannulate the PD and placestent retrogradely. Generally, successful cannulation of thePD at the major papilla in normal anatomy has been reportedin 90–98% of cases. In patients with PD obstruction, cannu-lation of PD tends to be more difficult. Furthermore, cannu-lation of PD sites of stenotic pancreatodigestive anastomosis

with surgically altered anatomy is technically challenging.5,6

ERCP in patients who have undergone a Whipple procedureis especially technically difficult. Several authors havedescribed EUS-guided pancreatography and/or drainage ofthe PD in patients with inaccessible PD using conventionalERCP7–18 EUS-guided techniques for drainage of the PD areclassified into two types: the EUS-guided rendezvous tech-nique, and EUS-guided PD stenting. In our institution, webasically attempt the EUS-guided rendezvous procedure first.There are two major reasons for this strategy. One reason isthat the rendezvous technique can achieve ideal drainagefrom the ampulla or pancreatodigestive anastomosis and fun-damental treatment for stricture PD and anastomosis. Thesecond reason is that EUS-PD stenting requires more dilationof the needle tract than the EUS-rendezvous technique,leading to serious adverse events such as pancreatitis, pancre-atic juice leakage, bleeding, and perforation. A flow diagramdepicting EUS-guided PD drainage is shown in Figure 4.

Several reports describe the technical success rate rangesof the EUS-guided rendezvous technique and PD stenting to

A B C

D E F

Figure 3 One complication caused by the endoscopic ultrasonography (EUS)-guided rendezvous technique for decompression ofpancreatic duct (PD). (A) Fluoroscopic image demonstrates a transgastric pancreatogram. (B) A guidewire is inserted via the sheath ofa 19-guage fine-needle aspiration (FNA) needle and passes across the stricture of PD as a result of pancreatic carcinoma. (C) Fluoroscopicimage shows a 7-Fr stent being placed across the stricture of PD. (D) Abdominal computed tomography reveals a pancreatic pseudocystwith an aneurysm of the splenic artery. (E) Selective angiography shows an aneurysm of the splenic artery. (F) Embolization of theaneurysm being done to prevent rupture of the aneurysm.



be 77–92% and 25–100%, respectively. There are severaltechnical points for the improvement of the success rate ofEUS-guided PD drainage. Adjusting the direction of theneedle before puncturing allows greater success rates. If aguidewire cannot be introduced downstream, the rendezvoustechnique is not effective. Patients who underwent the EUS-guided technique were examined in a prone position. Influoroscopy, we always confirm whether the front of theechoendoscope faces the right side of the patient. To make iteasy to aim the antegrade passage of the guidewire, it wouldbe better to orient the echoendoscope parallel to the long axisof the main PD.

Occasionally, antegrade guidewire passage across the stric-ture of the PD and the stenotic anastomosis is difficult. Thus,high selectability guidewires are ideal. We prefer a 0.025-inchguidewire (VisiGlide®; Olympus) as the first guidewire. If itis difficult to pass the stricture of the PD or papilla or anasto-mosis, another suitable guidewire such a 0.032-inch hydro-philic guidewire (Radifocus®; Terumo Co., Tokyo, Japan) isrequired. In such cases, we insert the ERCP catheter into thePD, and replace the stiff-type VisiGlide® guidewire with ahydrophilic guidewire via the ERCP catheter.

Dilation of the needle tract and stent insertion between thePD and the gastrointestinal tract is the most difficult aspect inEUS-guided PD stenting. With patients in whom weattempted PD drainage, chronic pancreatitis was present tosome degree. Hard parenchyma hinders the insertion of thedilation catheter and stent. In addition, adjusting the directionof the needle tract and the direction in which the catheter orstent is pushed is sometimes difficult. To enable a smootherprocedure, ultrasonographic imaging, which shows longitu-dinal guidewire depiction, and fluoroscopic imaging, whichshows the same scope position as that at the first puncture,should be maintained throughout the procedure.

During the follow-up period after EUS-guided drainage(mean 17.8 months, 3–34 months), recurrent abdominal pain

and acute pancreatitis caused by stent occlusion and recurrentstricture of anastomosis and PD stricture occurred in onepatient. The long-term outcome after a short-period stentplacement across the stenotic pancreatojejunal anastomosisremains unknown. However, in the present study, one instanceof stent placement across the pancreatojejunal anastomosiswas effective. We think this was because the length of thestenotic pancreatojejunum anastomosis was short, so thestricture may have been relieved by just balloon dilation andstent placement for a few months.These patients have chronicpancreatitis and perhaps the capacity for endocrine secretionwas already reduced. Consequently, symptoms improved dra-matically due to some improvement of the stricture.

In the present study, we encountered a pancreaticpseudocyst with aneurysm of the splenic artery as aprocedure-related adverse event. Fortunately, this complica-tion improved with selective embolization of the aneurysmand conservative treatment in acute pancreatitis. However,several studies report that complication rates of EUS-guidedPD drainage are high. We believe that much pancreatic juiceleakage between the stomach and pancreas as a result of highpressure in the PD leads to complications such as pancreati-tis, peripancreatic abscess, and aneurysm.

There are several limitations to the present studybecause of the small sample size and this being a retrospec-tive analysis.

In conclusion, EUS-guided PD drainage is feasibleand useful for the treatment of high-pressure PD due toPD stricture or stenotic pancreatodigestive anastomosis.However, this procedure is technically challenging, has ahigh rate of complications, and should be done only attertiary-care centers.

ACKNOWLEDGMENTS

WE ARE INDEBTED to Professor James M. Vardamanof Waseda University, Associate Professor Edward F.

Barroga, and Professor J. Patrick Barron, Chairman of theDepartment of International Medical Communications ofTokyo Medical University for their editorial review of theEnglish manuscript.

CONFLICT OF INTERESTS

AUTHORS DECLARE NO conflict of interests for thisarticle.

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Inaccessible PD using conventional ERCP

EUS-guided pancreatographysuccess unsuccessful

Percutaneous treatmentSurgical treatment

EUS-guided rendezvous technique

unsuccessful

EUS-guided PD stenting

Figure 4 Flow diagram of the strategy of endoscopic ultra-sonography (EUS)-guided drainage for failed conventional retro-grade access to the pancreatic duct (PD). ERCP, endoscopicretrograde cholangiopancreatography.



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endoscopic ultrasonography-guided pancreatic duct drainage after failed endoscopic retrograde...

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