EUS guided coloduodenostomy for management of a dilated donor duodenum and recurrent pancreatitis following pancreaticoduodenal transplant. These are our disclosures. 52-year-old male with history of type 1 diabetes complicated by end-stage renal disease, status post simultaneous pancreas kidney transplant 7 years prior presented with emesis and right lower quadrant abdominal pain. Labs were notable for a lipase of greater than 1500. Abdominal computed tomography scan noted acute interstitial pancreatitis. No prior history of or risk factors for pancreatitis were identified and it was determined not to be due to rejection of the donor organ. As depicted here, during his transplant a donor duodenum and pancreas was anastomosed to a jejunal loop in his right lower quadrant. CT scan was notable for a dilated donor duodenum with a decompressed efferent limb and upstream small bowel dilation. Imaging was suggestive of an anastomotic stricture versus torsion of the efferent limb causing outflow obstruction of the donor duodenum and subsequent pancreatitis. He continued to have recurrent episodes of pancreatitis. Transplant surgery was consulted who agreed with suspected afferent limb-like syndrome. Given surgical history and post-transplant status, advanced endoscopy was consulted for less invasive approaches. The plan was to perform an endoscopic ultrasound guided lumen opposing metal stent placement from the colon to the dilated donor duodenum for decompression and to evaluate the anatomy of the efferent limb. Standard 6-liter bowel prep was administered to the patient. Flexible sigmoidoscopy was performed to evaluate the rectosigmoid mucosa, which was unremarkable. A linear echoendoscope was advanced to the level of the rectosigmoid junction where a dilated fluid-filled loop of small bowel corresponding to the donor duodenum was identified adjacent to the bladder, correlating with its CT position. A 19-gauge needle was used to puncture the donor duodenum. 500 cc of normal saline in contrast was instilled into the donor duodenum to confirm location and provide adequate room for lumen opposing metal stent deployment. A cautery-enhanced 15 mm by 10 mm lumen opposing metal stent with a preloaded wire was used to create a coloenterostomy. The stent was then dilated under fluoroscopic and endoscopic guidance to 12 mm. Due to immaturity of the tract, the echoendoscope was exchanged for a neonatal endoscope and the duodenum evaluated. Then the donor duodenum, the ampulla. and efferent limbs were identified. The efferent limb appeared to take a right turn, but was not fully evaluated, given the pressure exerted on the newly placed stent by the endoscope. The decision was made to allow the stent to mature and bring the patient back for further evaluation. One double pigtail stent was placed through the lambs to prevent migration. The patient was discharged home from the endoscopy suite with a seven day course of antibiotics for potential bacterial translocation. Following our initial procedure, the patient reported profuse diarrhea, refractory to 16 milligrams of Imodium, and increasing dietary fiber. The decision was made to bring the patient back for more urgent reevaluation, as the placement of the lambs was thought to have caused a short gut-like syndrome. The double pigtail plastic stents were removed, and the donor duodenum was evaluated with a therapeutic endoscope. The previously noted acute angulation of the efferent limb had improved with decompression of the donor duodenum. The endoscope could be easily passed into the afferent and efferent limbs without resistance. Given the patient's symptoms and endoscopic findings, the decision was made to remove the lambs and leave two double pigtail plastic stents to provide a pressure relief mechanism and prevent further episodes of pancreatitis while minimizing diarrhea. Again, a 7-day course of antibiotics was administered for potential bacterial translocation. He was maintained on a regular diet. Upon 3-month follow-up, the patient had no recurrence of diarrhea, pancreatitis, or abdominal pain. This is a unique case of afferent limb-like syndrome causing recurrent acute pancreatitis from progressive dilation of the donor duodenum due to a compressed and angulated efferent limb. Endoscopic therapies targeting decompression of the dilated segment may provide clinical benefit. Our case demonstrates the effective use of EUS-guided lambs placement to create a coloenterostomy as an alternative treatment to surgical management.

EUS guided coloduodenostomy

pancreatitis

endoscopic ultrasound

duodenal stent placement

afferent limb-like syndrome