Endoscopic Ultrasound Directed Transgastric ERCP for Disconnected Pancreatic Duck Syndrome Finding the Edge to Bridge the Gap These are our disclosures. Roux-en-Y gastric bypass is the most commonly performed surgery for obesity. This makes traditionally ERCP challenging given the length of the afferent limb. Balloon assisted enteroscopy ERCP and laparoscopic assisted ERCP are complicated by suboptimal technical success rates and an inability to easily perform repeat procedures. EOS directed transgastric ERCP provides a solution with high technical and clinical success rates. A 60 year old female with a previous history of roux-en-Y gastric bypass presented with severe acute necrotizing pancreatitis. A CT scan demonstrated hemorrhagic pancreatic fluid collections from disconnected pancreatic duck syndrome. She was deemed not a suitable candidate for distal pancreatectomy and failed multiple attempts at percutaneous drainage of collections and exploratory operations over 3 months. MRCP performed showing a pancreatic fluid collection as a result of a disconnected pancreatic duct. Decision made to proceed with EOS directed transgastric ERCP. A linear echoendoscope was advanced to the remnant stomach. A hypoechoic structure was identified and thought to reflect a sand dollar sign and the anatomically excluded stomach. A 19 gauge needle was used for puncture. Instead of the remnant stomach, this outlined the pancreatic fluid collection and its communication with the pancreatic duct. The excluded stomach was then identified and punctured with a 19 gauge needle. In gentrian of contrast, confirmed the excluded stomach on fluoroscopy. The excluded stomach was inflated with irrigation and direct puncture was then performed with a 20x10mm hot axios lumidiposing metal stent. This created a gastric gastric anastomosis and was deployed under sonographic and endoscopic control. The stent was dilated to 20mm using a CRE balloon. In order to limit stent migration, decision was made to utilise endoscopic sutures to secure the stent to the gastric wall. The second suture was placed on the jejunal side. Next a duodenoscope was advanced through the lambs, then through the pylorus and to the native papilla. Pancreatic duct was cannulated with a wire guided sphincterotome. Pancreatogram demonstrated pextrophasation of contrast in keeping with disruption of pancreatic duct leaking to the collection. We were unable to pass the wire deep into the tail. A pancreatic sphincterotomy was then performed. A 5 inch by 12cm single pigtail pancreatic stent was then inserted. Initially she was well post procedure but on day 8 developed melina with fluid responsive hypotension and haemoglobin drop. After resuscitation and commencement of proton pump inhibitor an urgent gastroscopy was performed. This demonstrated blood evident that was fresh in the remnant stomach. The bleeding point was identified as a disrupted suture with active bleeding from the site. For haemostasis two haemostatic clips were then applied. She remained clinically stable and free of sepsis. At 6 weeks progress CT imaging showed resolution of the collection. A progress ERCP was performed via the lambs and the haemostatic clips remained in situ. CT imaging demonstrated healing of the duct and the wire was able to be placed through to the tail. A 5 inch by 15cm stent was then placed. There has been evidence of resolution of the collections clinically and radiologically. The pancreatic duct has now demonstrated to be healed and the previous upper GI bleed has now resolved. This case demonstrates that complex interventions for the pancreas can be performed in patients with Roux-en-Y anatomy using EDGE. EDGE for Disconnected Pancreatic Duct Syndrome was technically feasible and provided ease of access for repeat stenting procedures and eventual leak resolution. Endoscopic suturing has been described to limit stent migration but does have the potential to add a risk of bleeding.

endoscopic ultrasound

transgastric ERCP

disconnected pancreatic duct syndrome

Roux-en-Y gastric bypass

pancreatic fluid collection