Endoscopic ultrasound-guided pancreaticogastrostomy in a pediatric patient.

A 14-year-old boy was admitted for acute pancreatitis secondary to pancreas divisum. The patient failed to improve with conservative management. In addition, two separate conventional endoscopic retrograde cholangiopancreatographies (ERCPs) were attempted for endoscopic stenting for pancreas divisum. However both were unsuccessful in cannulation of the pancreatic duct despite secretin injection, spraying of the papilla with methylene blue, and precut minor papillotomy. Despite pancreatic rest and nutritional supplementation via percutaneous endoscopic gastrostomy (PEG) with jejunal extension, the patient had persistent abdominal pain and back pain, as well as failure to thrive. Therefore an endoscopic ultrasound (EUS)-guided pancreaticogastrostomy was performed for pancreatic duct drainage (▶Video1). A 7-Fr × 15-cm plastic double-pigtail stent was placed in antegrade fashion, with the proximal end in the stomach and the distal end in the small intestine (▶Fig. 1). The post-procedure course was complicated by a peripancreatic collection that was drained with a lumen-apposingmetal stent (LAMS). Nevertheless, 1 month after successful pancreatic duct drainage, the patient’s abdominal pain had resolved. Interventional EUS is a rapidly expanding field, and it has become a key technique in therapeutic endoscopy. It was initially described for the management of pancreatic fluid collections, but has expanded to include drainage of the biliary and pancreatic duct in the setting of failed conventional ERCP [1, 2]. EUS-guided drainage should not be used to compensate for a lack of ERCP skills [3]. But if conventional drainage has been appropriately attempted and failed, rather than risk a complication from ERCP, then EUS-guided drainage should be performed. We present the first reported case of EUSguided pancreaticogastrostomy in a pediatric patient after failed ERCP for management of pancreas divisum.