Okay, so a big thank you to Amitabh Praline and ASG for inviting me back as part of that transition, sounds like. I hold this course really dear to my heart. I was part of the original Cleveland first graduating class back in 2013 and I was so impressive that they invited me to be on faculty, so at least that's what I would like to believe. Okay, no disclosures. Okay, so I'm gonna be talking about disconnected pancreatic duct syndrome. We all know it probably now more as a sequelae of necrotizing pancreatitis. It can also be seen after pancreatic trauma and it's, you know, develops after a segment of necrosis leads to a lack of continuity between the viable secreting pancreatic tissue, usually in the body or tail that's been disconnected from the pancreatic head, connecting it to the GI tract. And the problem is, is that the upstream disconnected and functional segment of the pancreas, right, continues to secrete pancreatic juice that no longer can be drained normally through the pancreatic head and into the duodenum and then this can lead to problems such as recurrent pancreatic fluid collections, refractory external pancreatic fistula and chronic abdominal pain and even acute recurrent pancreatitis of the body tail. And really surgery has remained the cornerstone for management. Patients with this problem and the conventional surgical approaches have really either been resection or internal drainage. But surgery, you know, can be really difficult, especially in the presence of local inflammation, extensive, oftentimes at this point, the patients have extensive venous collaterals in the operative field and it can be associated with pretty significant morbidity. And so advancement in therapeutic endoscopy has really opened up an exciting new field of minimally invasive therapeutic options for the management of this. Okay, so this is my case. I had a 53-year-old guy, history of cholecystectomy, complicated by a bile leak, pretty common. So then he had an ERCP at an outside hospital, I feel obliged to say that, to treat the bile leak that was unfortunately complicated by really bad post-ERCP necrotizing pancreatitis. So he was treated with EOS-guided cyst gastrostomy, direct endoscopic necrosectomies to completion. And because at the time we knew that he had a disrupted pancreatic duct in the neck, it was actually pretty close in the neck head, so it was pretty early on, or pretty distal. Therefore, the decision was made to leave in kind of double pigtail stents with the plan to kind of leave them in just indefinitely. And he did well for years until he developed recurrent abdominal pain. So this is his CT scan. Oops, sorry. And so what we saw was what looked like an abscess that was seen in the left lower abdomen. Okay, this is supposed to be clearly showing that. And the sinogram really kind of demonstrated that there was this connection between the left lower quadrant fluid collection or abscess and then that pancreatic body tail. So what's going on? And what do we do about it? I also don't bite, really. Katie. Okay, so in the interest of time, what we thought was happening was that we had intact double pigtail stents, right? So into the area where the walled-off necrosis had been present, had been treated. And we had a significant amount of pancreatic, of pancreatic parenchyma that was still functioning in the body and tail. And what we think happened was that the duct, the area of the disconnected duct in the body started stenosing and then closed up. But that functioning pancreatic body and tail is still secreting juice. And what ended up happening is it kind of blew out in the tail and then collected into this collection, this abscess in the left lower quadrant. Okay, so that's what we think is happening. So what do we do about it? Okay, drain the distal pancreas. How? Okay, so you want to place the stent EOS guided from where to where? Okay, so stomach into the pancreas, pancreatic duct. Okay. I mean, it's gotta be multidisciplinary with hepatobiliary surgery as well, to just get them involved to see if you run into complications. Yeah, so exactly. So we had a multidisciplinary conference. We went over this guy is like totally functioning, has done extremely well after his whole episode of necrotizing pancreatitis and all of that that happened so long ago. He would really like to, he also does not have diabetes. I didn't really say this, but he also actually does not have diabetes at this point. He has a lot of functioning pancreas left. So the surgeons, you know, definitely said that they could offer the idea of a pretty extended distal pancreatectomy. But with that, there was almost a guarantee that he was no longer gonna have any functioning pancreas left. He just had a little bit of his head left. So that was not really a great option. A drainage procedure would be very difficult. He had a lot of different various collaterals and whatnot with his venous structures and vessels. And the duct wasn't really that dilated. So it just would have been a much more difficult procedure for them. They weren't in favor of that. IR felt like they could easily put a PERC drain into that left lower quadrant abscess, but they didn't really have anything else to offer. So we went ahead and tried to see if we could reconnect the duct endoscopically. So this is my video. And what I'm gonna do for this is I'm gonna play the video, but then stop and talk about it. I have always thought that I should redo this video because it could be done better. But I kind of like the idea that we are talking about all the things that are not great about the video as well during this conference. So, okay. And originally it did have audio, but I'm gonna try to talk about it. So we decided to just go down and do an ERCP, just retrograde fashion, just see what it is that we're seeing. So as you can see, I have floral images on the right and endoscopic images on the left. I don't think the endoscopic images provide anything with this. By the time I thought it was really cool to see them both happening at the same time. And I spent a lot of time trying to line up the video to what I was doing, to what was going on floral. Probably not needed. Shaper, everyone says, you know, six to eight hours. No, this was like weeks and hours of trying to get this. And then to go through the two hours of images, of video for all of these different aspects. Woo, anyhow. Okay, where is my? Oh, so just dedication. Okay, so yeah, see how it's all going at the same time? Pretty cool. Okay, so, but wait. Oh wait, stop, hold on. Oh, shoot. I need to figure out how to pause. Oh no, how do I pause this as I'm doing this? Okay. Okay, great, so you see the wire, you see the PD being cannulated. Contrast is being injected. The wire is kind of just going. And then, and see then, now I focus on the floral because that's more interesting, obviously. So in this image, you're seeing the double pigtail stent. You're seeing the pancreatic head, neck. Okay, so then you see contrast that is just extravasating into the area of the Waldorf necrosis. And then what you can also see, oh. Okay, one of the other things that we had talked about is using still images as part of your video, right? One of the things to just make sure when you're doing that is that if you do it like on a PowerPoint or whatever, it's that when you have your text, if the spell check doesn't recognize it, you're gonna have a little squiggly sign, right? When you're doing a PowerPoint presentation, it doesn't matter, it goes away. But when you're doing a screenshot of it or whatever, it stays there and then you have it on your video and that's like just poor form. Okay, so extravasation of contrast into the Waldorf necrosis. And then you can actually see, which is kind of cool, the contrast actually just dipping down in the area of the duct disruption. Oh, you see what just happened? I saw what happened. My mouse moved. Okay, so the ERCP, the wire's not going anywhere, so then we decided that we're gonna try to do this EOS-guided access of the pancreatic duct. So here's the EOS showing the body of the pancreas, the pancreatic duct. It's dilated, it's not dilated that much, so 3.7 in the body is like kind of just a little bit generous, but not super generous. And so what does that mean? It's making the target for your EOS-guided access a little bit more tricky. And the other thing, so colored Doppler is used, obviously, to make sure there's no intervening vessels. That's not really a great view of that, since Doppler was really far down from where we were gonna be, but in any case. So this is gonna be an example of looking at both your fluoro and your EOS. Again, I don't think the fluoro added anything here, so if I were doing this again, I probably wouldn't add the fluoro, the side-by-side. The other thing, and I'm not gonna, yeah. Can you give the fellows some tips about how to do EOS-guided pancreatic duct puncture? Puncture. Give them a few tips about how you do your technique. Yeah, so one of the things that is really helpful is to make sure that you're in a very stable position. The other thing, depending on where you're trying to access, what you wanna do is you wanna try to position the duct in the same angle that your needle is going to come out, okay? And that's gonna be really important. The other, I didn't do this for this one, but one of the other techniques, especially when you have a small duct, that you can consider. Oh, and then I'm also using a pretty big needle, and the reason why I'm using the needle is because I need to use different devices through the needle in order to do what I wanna do. So the 19-gauge needle. I'm not sure how many of you guys are using the 19-gauge needle, but it is much harder to manipulate and to use than your usual 22 needle, so just to keep that in mind. I'm actually using a 19-gauge access needle, and that is the one where you have the needle that goes through the sheath, and then once you access, you can pull the needle out and then leave that catheter in that doesn't have that sharp needle edge. If you have a small duct, one of the techniques that you can do is you can actually access it, aspirate, and then put contrast in to confirm that you're in the duct and then you can actually even put more contrast or more saline to try to blow up the duct a little bit. Once you do that, I mean, once you do any of this, you're kind of committed, but once you do that, you're committed. You're doing a lot of intervention to the duct. Is there anything else that you wanted me to add? No, okay. Okay, another thing. I'm not gonna go back on this video, but I have a really weird cut where it kind of flickers. Totally would take that back if I could. It's distracting. Okay, so here the duct is punctured. We're gonna have said that we've aspirated. We're injecting, we inject contrast, delineate kind of where our duct is going, and then now we're trying to put in the wire. Now, I sped this up. Oh, sorry. So just to get the full pink radiogram here, which I thought was kind of cool. So this, there was, you can't really see it here, but there was some contrast that dribbled into that left abdominal cavity, but then you can kind of see there is just complete obstruction in that area of the pancreatic neck. So there is no contrast that's going at this point into the area of the wall of necrosis or the duct in the head. Okay, so and then eventually with more contrast, you see contrast going actually into the area of the, where this is gastrostomy had been, and then also into the wall of necrosis. I did speed up this video, and part of me wishes that I hadn't. So this is very intentional. When you are putting the wire through your access needle, you have to be very careful that you're not going in and out too fast because there's always a concern that you're gonna be shutting the wire. So I sped this up just because it's really painful to watch the wire go down, hit the obstruction, come back, go down, and go back, and eventually you'll see kind of where we're at. So what we ended up doing, because the wire was not going through the duct that was obstructed in the body, we ended up putting a four millimeter dialening balloon. We thought that that would add just a little bit more stability to the wire and give us a little bit more pushability. We advanced that through our gastric fistula down to the area of the obstructed duct, and then we're able to kind of direct the wire and push it through. So now the wire is seen in the, you know, just kind of coiling in the area of the wall of necrosis cavity. And the decision was made because we knew why we were going in here that we wanted to put in, we wanted to just make sure that we could open up this duct. So we decided to leave a seven inch stent from the stomach ending into the pancreatic duct, actually going through the pancreatic duct ending in the area of the wall of necrotic cavity. Okay, so that's what we have at this moment. Any questions at this time? Actually, we just used, I don't know if we even thought about it. I think we just decided to see if it was gonna push through, and it did pretty easily. It was a 19 gauge needle, so I think that probably helped, but the shaver brings up a really good point. So a lot of times, you know, you're not gonna be able to get anything through that really thick gastric wall and then through the pancreas, and you might need to needle knife your way in. So Brooke, a quick question. At some point, it looked like wire was heading down into the pancreatic head and to the denim. Were you able to bridge that total disconnection? Yeah, so I'm gonna continue on. So what I didn't say was that we already did this. So we had done this, and we'd gone the wire, well, we thought, and we thought we had it through the head, and we came out, we left it in order to do what we were gonna do was an ERCP to see if we could go retrograde and then use that wire and do like a parallel wire rendezvous or even, I think we were gonna do a parallel wire because we didn't really feel like we had a lot of wire. And then we went down with the duodenoscope, and the wire was nowhere to be found, even though, and then we realized that the wire wasn't actually in the head of the pancreas and was just kind of coiling in the area. And then we were like, okay, it's fine. We're gonna go back, go back and then put in a stent, and then we lost wire access. I mean, this might have been like a three hour, I don't care. It was a really long procedure because now at this point, we're really, really committed. We've like poked the duct, we put contrast in, we've done a lot. So then we went back down and we were really happy that we got it. And then we decided we're just gonna leave the wire, put the stent in, because now we've done what we accomplished. But, so the stent's in, but then we decided, okay, well, let's just try it one more time. So sometimes less is more. And this is another point, one of the points that we talked about earlier is just because you can, doesn't mean you should and really go in intentionally with what you wanna do. But so we went in to do the ERCP retrograde and see what we could do. We put the wire, and the wire just happened to follow the stent. And then even cooler, the wire just said, hey, I'm just gonna follow the duct. So you see the stent going into the stomach, but the wire went all the way into the tail. You have contrast seen in the tail. And so then we went ahead and put a five French stent in, in order to bridge the disconnection. We left the seven French stent in, and then we brought the patient back many weeks later. And we, um, pulled out the stent, we put in a bigger stent, a seven French stent. And then we actually even put in a small anchoring stent, I believe, just because we really didn't wanna lose the stent. And then we pulled back into the stomach and removed that gastropancreatic stent. And this is what we were left with. So the duct was then reconnected, trans-papillary. And we left that stent in for quite a long time. We upsized it. So this was many, many months of follow-up. Then we took the stents out, and he did really, really well for a really long time, until he kinda came back with a stenosed stricture in that area, and we just repeated the same thing. And he's done really well. I haven't really done a lot of follow-up recently, which maybe is good news. No news is good news. So, good, perfect. To end this. So, EUS-guided pancreatic duct access for reconnection may be an option for duct disruption. It could maybe be considered in a very, very select group with a multidisciplinary approach. Long-term follow-up data is really limited since the N is very small for these patients. And lots of limitations to this procedure, such as lack of dedicated therapeutic EUS devices. That's all I have. Wow. Thank you.

disconnected pancreatic duct syndrome

necrotizing pancreatitis

pancreatic trauma

therapeutic endoscopy

ERCP