Endoscopic ultrasound-guided pancreatic duct drainage using antegrade stenting.

Endoscopic ultrasound (EUS)-guided pancreatic duct access in patients with an inaccessible papilla or failed endoscopic retrograde cholangiopancreatography (ERCP) has been reported previously [1, 2]. This technique consists of the EUSguided rendezvous technique, and EUSguided pancreatic duct stenting via the stomach (pancreaticogastrostomy), or the duodenum (pancreaticoduodenostomy) [2]. However, the technical success rate of the EUS rendezvous technique is not very high [3], and it is not indicated in patients with altered anatomy, for example following a Roux-en-Y procedure. Stent occlusion is a risk of EUS-guided pancreaticoduodenostomy, and it may easily occur because of food impaction. Novel technical tips for EUS-guided pancreatic duct antegrade stenting are presented here (●" Video 1). A 66-year-oldwomanwas admitted to our hospital because of abdominal pain. She had previously had chronic pancreatitis. On magnetic resonance cholangiopancreatography (MRCP) and EUS imaging, the pancreatic duct was observed to be dilated from the head of the pancreas, around which a pancreatic stone was also seen. This pancreatic stenosis was treated using a pancreatic stent. First, we performed ERCP, through which we observed the stenosis of the pancreatic duct. However, wewere unable to pass the ERCP cannula through the stenosis site (●" Fig.1). Next, the scope was changed from a duodenoscope to a convex echoendoscope. To avoid any intervening vessels, the pancreatic duct was first punctured using a 19-G needle under Doppler imaging (●" Fig.2). After pancreatic juice had been aspirated, contrastmediumwas injected, and images of the pancreatic duct were obtained (●" Fig.3). Then, a 0.025-inch stiff guidewire was inserted, and was easily advanced into the duodenum through the stenosis. Next, the 19-G needle was exchanged for an ERCP catheter to dilate the fistula (●" Fig.4). Although an EUS-guided rendezvous approach was considered, EUS-guided antegrade stentingof the pancreatic duct was attempted because no leakage of pancreatic juicewas seen on endosonographic imaging. The 7-Fr straight plastic stent was inserted antegradely, from the duodenum to the pancreatic duct (●" Fig.5). No adverse events were seen. Although validation is required in a prospective clinical trial, this novel technique appears to be safe and effective as an option for EUS-guided pancreatic duct drainage. Fig.1 Endoscopic ultrasound (EUS)-guided pancreatic duct antegrade stenting was performed on a 66-year-old woman. At endoscopic retrograde cholangiopancreatography (ERCP) the guidewire was successfully advanced into the pancreatic duct through the stenosis, but the ERCP cannula and other devices, including the dilation catheter, could not be advanced.