EUS-guided pancreatic gastrostomy approaches for complete pancreatic duct obstruction, a case series. Here are our disclosures. Complete pancreatic duct obstruction may occur due to advanced friction of the pancreatic duct due to chronic pancreatitis or malignancy, pancreatic stone disease, pancreatic disconnection secondary to trauma or pancreatitis, postoperatively, or another etiology. Patients may be asymptomatic or can present with pain, pancreatitis, or associated complications such as a leak or a pseudocyst. Treatment options include conservative management, treatment of the underlying etiology, EUS-guided therapy, or surgery. We present a series of three patients with complete pancreatic duct obstruction treated with EUS-guided pancreatic gastrostomy. The first patient is a 45-year-old female with a history of necrotizing pancreatitis and a disconnected pancreatic duct. She had recurrence of a pseudocyst after migration of her transmural stents, which was treated with a new cyst gastrostomy. Despite this, she developed recurrent acute pancreatitis of the disconnected pancreas and epigastric pain. The second patient is a 65-year-old female with a history of an ampillary adenoma for which she underwent surgical ampullectomy twice. Following her second surgery, she developed acute pancreatitis and epigastric pain and was referred for further evaluation. The third patient is a 58-year-old female with a history of chronic pancreatitis who developed pancreatic cancer. She had been treated with a pancreatic and biliary stent in the past. Following chemotherapy, she was referred for reevaluation. The pancreatic stent was removed during EUS and ERCP, following which there was no filling of the pancreatic duct upstream from the stricture. On MRCP imaging, the first patient had a disconnected pancreatic duct in the body tail with mild duct dilation. The second patient had complete stenosis of the pancreatic duct at the level of the major papilla, and the third patient had a markedly dilated pancreatic duct in the body and tail with debris and dilated side branches and an abrupt cutoff of the duct in the neck of the pancreas. On ERCP, the pancreatic orifice could not be identified in patient 2 despite using methylene blue and secretin. Obstruction of the pancreatic duct was known about in patients 1 and 3 from before. All three patients were therefore offered pancreatic gastrostomy. The pancreatic duct was identified from the stomach and accessed using a 22-gauge needle. The needle had been primed with saline prior to duct access. Contrast was subsequently injected through the needle. Pancreatography confirmed a complete duct obstruction. A 0.018-inch wire was advanced into the duct, and the needle was removed. The cyst gastrostomy tract was traversed using a 4-french, 4-millimeter angioplasty balloon catheter, which was advanced gently across the gastric wall and into the pancreas. The tract was then balloon dilated and treated with a 3-french pancreatic stent with the pigtail inside to help anchor the stent. The stent was noted to be longer than anticipated on fluoroscopy and endoscopy. It was therefore shortened using endoscopic scissors. The cut end of the stent was removed using a snare. The previously placed cyst gastrostomy stents can be seen in the background. Case 2. The pancreatic duct was identified and accessed using a 19-gauge needle. Once the tip of the needle was confirmed to be in the pancreatic duct, contrast was injected. There was filling of the duct in the tail, body, and neck of the pancreas. A 0.025-inch angled wire was then advanced into the duct, and care was taken not to aggressively advance the wire to minimize the risk of shearing. The wire can be seen coiling inside the head of the pancreas. Despite multiple attempts, the wire could not be advanced into the duodenum. The wire was therefore left in the head of the pancreas, and the needle exchanged for a 4-millimeter fillery balloon dilator. Contrast injection confirmed no filling of the duodenum. The tract was then balloon dilated, and subsequently a second wire was placed inside the duct. The patient was treated with a 3-French stent and a 5-French single-pigtail stent. Case 3. This patient had a history of chronic pancreatitis and pancreatic cancer. She had changes of chronic pancreatitis on EUS, and access to the pancreatic duct was not easy despite a dilated duct. A 19-gauge needle was advanced into the pancreatic parenchyma, and initially it was not felt to be inside the main duct. The needle was therefore withdrawn, and once it was felt to be in the main duct, contrast was injected. There was marked dilation of the pancreatic duct with no filling past the body towards the neck of the pancreas. Given the patient's history of pancreatitis, access to the pancreatic duct was difficult. A cannula and dilation balloon would not traverse the tract. A 6-French sister tome was therefore used. Following this, the tract was balloon dilated, and a second wire was placed inside the tract. A 5-French single pigtail stent was placed inside the pancreatic duct. Given that the patient had a markedly dilated duct with debris within it, and cautery had been used to access the duct, the patient was treated with a fully covered metal biliary stent. All three patients tolerated the procedures well and were discharged one to two days later. The choice of stents is summarized on this slide. The third patient's metal stent was replaced with a plastic stent one month later. All three patients are doing well at two-month follow-up. Some useful endoscopic techniques are summarized on this slide. U.S.-guided pancreatic duct drainage provides an effective, minimally invasive approach for the management of patients with complete pancreatic duct obstruction. Several technique and device modifications can be utilized to overcome challenges related to creating a pancreatic gastric tract for successful stent placement.

EUS-guided pancreatic gastrostomy

pancreatic duct obstruction

pseudocysts

EUS-guided therapy

pancreatitis