EUS-Guided Pancreatic Duct Drainage

Endoscopic ultrasound (EUS)-guided pancreatic duct drainage (EUS-PD) is a second-line procedure that allows drainage of the pancreatic duct when ERCP, the primary endoscopic procedure for pancreatic duct drainage, is either not feasible or unsuccessful.¹ EUS-PD is performed in the fluoroscopy room by an experienced operator assisted by well-trained personnel in properly sedated and monitored patients at a facility with multidisciplinary backup. The availability of appropriate equipment and a wide array of devices cannot be overemphasized. EUS-PD complements pancreatic ERCP making endotherapy available to complex patients who would otherwise have to undergo surgery or percutaneous procedures for duct decompression or would have to face the suboptimal prospect of medical treatment. Depending on patient anatomy, operator expertise, and predictability of ERCP difficulty, EUS-PD can be performed within the same session of failed ERCP.² Alternatively, EUS-PD can be scheduled in the future. Following transgastric or transduodenal EUS-guided pancreatography, drainage is established by means of transmural, transpapillary (either retrograde or antegrade), or a combined approach.¹,² A successful index EUS-PD may need follow-up procedures for stent revision, which no longer require an EUS endoscope.³

INDICATIONS

The triad of (1) typical clinical manifestations, associated with (2) imaging evidence of pancreatic duct obstruction/disruption, in the setting of (3) established pancreatic disease, warrant EUS-PD whenever ERCP is unsuccessful, with the possible exception of known resectable pancreatic malignancy. There are three main reasons for failure of pancreatic ERCP: difficulty in access to the papilla (as in surgically altered upper GI anatomy
or in duodenal strictures), in cannulation (as in minor papilla or in prior biliary sphincterotomy) or in guidewire access to blocked duct segments (as in transected or disrupted ducts). Therefore, ERCP failure can often be anticipated prior to undertaking ERCP (e.g., acute relapsing pancreatitis post-Whipple⁴; disconnected pancreatic duct syndrome [Fig. 34.1]; history of previous failed pancreatic ERCPs). However, on other occasions the indication for EUS-PD may arise during ERCP (e.g., failed guidewire passage across tortuous chronic pancreatitis strictures or impacted pancreatic duct stones; failed minor papilla cannulation of newly diagnosed divisum). As in the examples above, all indications for EUS-PD include varying combinations of the following triad elements.

FIG. 34.1 Disconnected pancreatic duct syndrome as a late sequela of acute necrotizing pancreatitis. An intervening pseudocyst (*) is located between the pancreatic duct in the head and the dilated upstream pancreatic duct in the body and tail (arrows). The patient is having acute relapsing pancreatitis. Transgastric puncture of the pancreatic duct in the body of the pancreas, with the scope oriented toward the tail. The two-stage treatment plan involves pancreaticogastrostomy to temporary decompress the duct, followed by rendezvous reconnection of the disconnected pancreatic duct at a follow-up procedure through the mature pancreatogastric fistula.

Clinical Manifestations

1. Severe, persistent pancreatic-type abdominal pain
2. Acute relapsing pancreatitis
3. Refractory pancreatic fistula

Background Diagnoses

1. Chronic pancreatitis
2. Pancreatico-enterostomy stricture (most commonly, post-Whipple)
3. Pancreas divisum
4. Pancreatic trauma (including surgery)
5. Pancreatic cancer⁵,⁶
6. Acute necrotizing pancreatitis

Underlying Pancreatic Duct Anatomy

1. Pancreatic strictures
- a. Ductal (e.g., chronic pancreatitis or pancreatic duct adenocarcinoma)
- b. Papillary (e.g., minor papilla or major papilla after biliary sphincterotomy)
- c. Anastomotic (e.g., pancreato-jejunostomy)
2. Pancreatic duct stones
3. Pancreatic duct disruption
4. Disconnected pancreatic duct

PREPARATION

1. Patient evaluation and consent: Thorough clinical evaluation, including cross-sectional imaging and MRI pancreatography (ideally with IV secretin), is essential to establish the indication and to define procedural approach. Depending on anticipated likelihood of ERCP failure and on institutional policy, informed consent is obtained for both ERCP and EUS-PD.
2. Periprocedural medications: Antiplatelet/anticoagulation agents and antibiotic prophylaxis should be managed per American Society for Gastrointestinal Endoscopy guidelines.⁷
The value of rectal nonsteroidal anti-inflammatory drugs and of intravenous hydration in decreasing the risk of postprocedural pancreatitis has not been established for EUS-PD, but are reasonable to consider.
3. Sedation: The level of sedation required for EUS-PD is comparable to that of complexity level IV ERCP. Monitored anesthesia care or general endotracheal intubation are most common in the United States; however, nurse- or endoscopist-administered propofol can also be used to provide optimal sedation.