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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 274-275

EUS-guided transmural pancreatic duct interventions for relief of pain in patients with chronic pancreatitis and failed ERCP


1 Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Surgery, Division of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission13-May-2020
Date of Acceptance11-Jun-2020
Date of Web Publication05-Aug-2020

Correspondence Address:
Dr. Surinder Singh Rana
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eus.eus_46_20

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How to cite this article:
Rana SS, Sharma R, Gupta R. EUS-guided transmural pancreatic duct interventions for relief of pain in patients with chronic pancreatitis and failed ERCP. Endosc Ultrasound 2020;9:274-5

How to cite this URL:
Rana SS, Sharma R, Gupta R. EUS-guided transmural pancreatic duct interventions for relief of pain in patients with chronic pancreatitis and failed ERCP. Endosc Ultrasound [serial online] 2020 [cited 2020 Sep 20];9:274-5. Available from: http://www.eusjournal.com/text.asp?2020/9/4/274/291503



Dear Editor,

In 3%–10% of patients with chronic pancreatitis (CP), ERCP may not be possible due to the presence of various anatomical factors.[1] EUS-guided pancreatic duct (PD) interventions have recently evolved as an alternative therapeutic option in patients with failed ERCP.[1],[2],[3],[4] EUS-guided PD interventions are categorized as either rendezvous-assisted ERCP (RAE) or anterograde PD drainage (A-PDD).[2] In this letter, we report our center's experience with various EUS-guided PD interventions.

The endoscopic database was retrospectively searched to identify patients with CP who underwent an attempted EUS-guided PD intervention. After puncturing PD from either stomach or duodenum, RAE was attempted in all patients. If RAE was unsuccessful, a guidewire was secured in PD and the transmural tract was dilated using a 6 Fr cystotome. At the endoscopist's discretion, the transmural tract was further dilated using either a wire-guided dilating balloon or a bougie dilator. Thereafter, a 5 or 7 Fr stent was placed to establish a gastro-pancreatic or duodeno-pancreatic drainage. Contrast-enhanced computed tomography was performed after 2 months of the procedure to ascertain the position of the transmural stent [Figure 1]. The endoscopic treatment was repeated if there was recurrence of abdominal pain along with dilatation of the main PD on imaging. Using a duodenoscope, the transmural fistula tract was dilated after cannulating it alongside the previously placed stent, followed by replacement of the stent.
Figure 1: Computed tomography abdomen: pancreatico-gastrostomy stent seen in situ with decompressed main pancreatic duct. The stones at the neck of the pancreas can be seen adjacent to the distal end of the stent

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Twenty-one patients underwent EUS-guided PD intervention. EUS pancreatogram could be obtained in all patients, but RAE could be successfully completed in nine (43%) patients. Hence, 12 patients (all males: mean age: 39.2 ± 7.2 years) underwent A-PDD [Table 1]. The mean maximum main PD diameter was 8.2 ± 2.0 mm. A transgastric approach was used in 11 (91.7%) patients. The procedure was technically successful in all the 12 patients, and a 5 Fr stent was placed in nine patients and a 7 Fr stent in three patients. Straight stent was used in seven patients and pigtail stent in five patients. Three (25%) patients had mild self-limiting abdominal pain that required intravenous analgesics and one patient had minor self-limiting bleed. All patients had complete relief of pain at 4 weeks after the procedure.
Table 1: Baseline characteristics of the study patients

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Over a mean follow-up period of 27.3 ± 16.9 months, seven (58.3%) patients presented with recurrence of abdominal pain. In 5/7 patients (three patients with 5 Fr and two patients with 7 Fr stents; all straight stents), transmural PD stents had externally migrated and hence fistulous opening could not be identified. Three of these patients underwent surgery and two patients underwent EUS-guided celiac plexus neurolysis. In two patients, the fistulous tract was cannulated alongside the 5 Fr stent followed by its replacement with a 7 Fr stent. The remaining five patients with stent in situ are pain free till the last follow-up. In conclusion, EUS-guided PD drainage seems to be a safe and effective treatment option for patients with painful CP and failed ERCP. Stents with improvised design to prevent spontaneous migration are needed.

Acknowledgment

The authors acknowledge Dr. Sarakshi Mahajan, Resident, Department of Medicine, Pontiac, MI, USA, for proofreading as well as editing the manuscript for English Language.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chapman CG, Waxman I, Siddiqui UD. Endoscopic ultrasound (EUS)-guided pancreatic duct drainage: The basics of when and how to perform EUS-guided pancreatic duct interventions. Clin Endosc 2016;49:161-7.  Back to cited text no. 1
    
2.
Krafft MR, Nasr JY. anterograde endoscopic ultrasound-guided pancreatic duct drainage: A technical review. Dig Dis Sci 2019;64:1770-81.  Back to cited text no. 2
    
3.
Ergun M, Aouattah T, Gillain C, et al. Endoscopic ultrasound-guided transluminal drainage of pancreatic duct obstruction: Long-term outcome. Endoscopy 2011;43:518-25.  Back to cited text no. 3
    
4.
Matsunami Y, Itoi T, Sofuni A, et al. Evaluation of a new stent for EUS-guided pancreatic duct drainage: Long-term follow-up outcome. Endosc Int Open 2018;6:E505-E512.  Back to cited text no. 4
    


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