A 35-year-old female presented to the emergency department with abdominal pain. She had a complex past medical history notable for peptic ulcer disease requiring a pancreas sparing duodenectomy and subtotal gastrectomy with Roux-en-Y reconstruction and re-implantation of the pancreatic duct and common bile duct. She subsequently developed recurrent episodes of acute pancreatitis and chronic abdominal pain. Prior to her index endoscopy, she had multiple presentations to the emergency department for abdominal pain. On her first presentation, she was diagnosed with acute onchronic pancreatitis based on an elevated lipase to 287 units per liter, the presence of abdominal pain, and CT findings of acute interstitial pancreatitis. She was treated supportively and discharged home but returned to the emergency department two weeks later with recurrent abdominal pain. During her admission in the emergency department, she underwent a CT scan of the abdomen and pelvis that demonstrated a dilated pancreatic duct measuring up to 7 millimeters in diameter. In addition, she was noted to have punctate calcifications within the distal main pancreatic duct as evidenced here. She was also found to have evidence of pancreatic divism with both a dilated dorsal and ventral pancreatic duct. Significant peripancreatic inflammation and edema were found, consistent with a diagnosis of acute interstitial pancreatitis. Overall, the findings were thought to be consistent with pancreatic duct obstruction, causing pancreatic duct hypertension as a source of the patient's pain. An ERCP with stenting of the dorsal pancreatic duct was considered, however, given the patient's complex anatomy, a cannulation of the jejunal insertion site of the dorsal pancreatic duct was thought unlikely to be feasible and would make subsequent procedures or stent exchanges difficult. A surgical pancreatic coat jejunostomy was also considered, but the patient's abnormal anatomy likewise placed her at high risk of adverse events. Following a multidisciplinary discussion, the decision was then made to pursue an EUS-guided pancreatic coat gastrostomy. An echolendoscope was inserted into the gastric remnant and the pancreatic duct was identified using EUS. The pancreatic duct had a tortuous appearance and was dilated up to 5 mm in diameter. The pancreatic duct was then punctured using a 19-gauge needle from a position close to the gastrojejunal anastomosis. After the initial puncture, the needle was then slowly withdrawn in order to prevent a sub-epithelial injection. With the needle in place, contrast was then instilled into the pancreatic duct. A pancreaticogram was obtained under fluoroscopy confirming positioning within the pancreatic duct. Contrast was seen extending to both the dorsal and ventral pancreatic ducts. In addition, there appeared to be an obstruction at the location of the jejunal insertion of the dorsal pancreatic duct. With the echoendoscope in place, a 0.018 inch guide wire was then passed through the needle and into the main pancreatic duct. The end of the wire was able to traverse the jejunal insertion site of the dorsal pancreatic duct and was looped into the pancreatic opilary limb of the small intestine. Over the guide wire, a 3 mm angioplasty dilating balloon was passed, which was then used to dilate the jejunal insertion of the dorsal pancreatic duct, main pancreatic duct, pancreas, and gastric wall. Here, the same dilation is seen progressing under endosonographic vision. Following dilation, one 3-inch by 12-centimeter plastic stent with a single pigtail was advanced through the dorsal pancreatic duct and across its jejunal insertion site. The pigtailed end was deployed in the pancreatic opilary limb of small intestine and the straight end into the gastric remnant. Almost 4 centimeters of the straight end of the plastic stent were left in the remnant's stomach to decrease the risk of migration. On follow-up EUS examination, the overall appearance of the pancreas was much improved. The pancreatic duct was much less dilated, and compared to previous endosonographic images, there was less edema, lobularity, and stranding. A repeat CT scan of the abdomen and pelvis also demonstrated resolution of the patient's peripancreatic inflammation and edema with a now normal-caliber pancreatic duct. Following the initial procedure, the patient recovered well without worsening pain or other adverse events. She was able to tolerate a diet and was discharged on postoperative day 1. She returned for a second procedure and stent placement in 3 weeks, which was performed as an outpatient procedure. In the interim, she had no further episodes of pancreatitis and reported improving abdominal pain with a decreasing narcotic requirement. For the second stent placement, the pancreatic duct was first cannulated at the prior pancreatic stent insertion site using a slim-tipped catheter. A wire was then passed across the pancreatic duct and into the pancreatic opilary limb of small intestine. Over the wire, an angioplasty balloon was passed and used to further dilate the pancreatic duct. Here, dilation of the gastric wall is seen under endoscopic vision. Once dilated, a second 3-french-by-12-centimeter pancreatic stent was then placed into the pancreatic duct and confirmed under fluoroscopic vision. Following the second procedure, the patient was discharged on the day of procedure without adverse events. She returned to clinic for follow-up and reported a significant reduction in her baseline blood pressure. She returned to clinic for follow-up and reported a significant reduction in her baseline abdominal pain. In addition, her need for breakthrough narcotics significantly decreased. She also reported improvements in her appetite and overall quality of life. At 6-month follow-up, the patient continues to do well and has had no further admissions for pancreatitis. This case demonstrates the utility of using small-caliber devices, such as a 0.018-inch guide wire and angioplasty balloon, for the endoscopic creation of a pancreatic gastrostomy. This technique was well-suited to managing the sequelae of chronic pancreatitis in a patient with complex post-surgical anatomy and pancreatic divism. Endoscopic pancreatic gastrostomy may be considered in cases where traditional methods of pancreatic duct access, such as long-limb ERCP with minor papillotomy, are unfeasible or at high risk for adverse events.

35-year-old female

complex medical history

abdominal pain

acute pancreatitis

chronic abdominal pain