- Email: [email protected]
EUS rendezvous for pancreatic stent placement during endoscopic snare ampullectomy
Brief Reports
In our report we have tried to emphasize the special circumstances in this case, that is, a trifistula, and the novel therapeutic approach taken. DISCLOSURE None of the authors have anything to disclose. Abbreviations: ALP, alkaline phosphatase; ALT, alanine aminotransferase; CBD, common bile duct.
3. Sandblom P, Jakobsson B, Lindgren H, et al. Fatal bilhemia. Surgery 2000;127:354-7. 4. Glaser K, Wetscher G, Pointner R, et al. Traumatic bilhemia. Surgery 1994;116:24-7. 5. Lee D, Chitturi S, Kench J, et al. Transjugular liver biopsy effecting changes in clinical management. Aust Radiol 2003;47:117-20.
Division of Gastroenterology-Hepatology, Department of Internal Medicine (O.M.B.), Department of Radiology (S.S.), Department of Pathology (J.W.), University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA.
REFERENCES
Reprint requests: William Silverman, MD, Division of Gastroenterology-Hepatology, 200 Hawkins Dr, 4553 JCP, Iowa City, IA 52242.
1. Brown CY, Walsh GC. Fatal bile embolism following liver biopsy. Ann Intern Med 1952;36:1529-33. 2. Clemens M, Wittrin G. Bilha¨mie und ha¨mobilie nach Reitunfall, Vortag 166. Hamburg: Tagung Nordwestdeutscher Chirurgen; 1975.
Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.01.027
EUS rendezvous for pancreatic stent placement during endoscopic snare ampullectomy Joseph Keenan, MD, Shawn Mallery, MD, Martin L. Freeman, MD Minneapolis, Minnesota, USA
Placement of transpapillary pancreatic stents has been shown to decrease the risk of post-ERCP pancreatitis in a number of high-risk settings.1,2 Pancreatic stent placement is considered to be particularly important after endoscopic ampullectomy.3-5 However, even in the most experienced hands, pancreatic cannulation and stent placement are not always successful.6 Failure may be the result of atypical anatomy, pancreatic duct obstruction, edema, tumor infiltration, postoperative changes, or cautery artifact after endoscopic ampullectomy. Avariety of techniques have been used to facilitate difficult retrograde pancreatic duct cannulation, including administration of secretin,7 spraying methylene blue on the surface of the papilla,8 and even percutaneous ductal access.9 Recently, the technique of EUS-guided rendezvous pancreatic and bile duct access has been described.10-15 By accessing a pancreatic or bile duct by the transgastric or transduodenal route, a guidewire is placed anterograde through the ampulla, thereby aiding retrograde cannulation by ERCP. The current case describes the first reported to our knowledge of the use of EUS rendezvous for pancreatic stent placement during endoscopic snare ampullectomy.
A 71-year-old woman who was remotely post cholecystectomy was seen for acute pancreatitis of suspected biliary
etiology, with findings of abnormal liver chemistries and a dilated bile duct at transabdominal US. Initial ERCP demonstrated a prominent ampulla without obvious neoplastic transformation. Neither the pancreatic nor bile ducts could be initially cannulated; therefore, a precut ‘‘fistulotomy’’ was performed and biliary sphincterotomy completed. After sphincterotomy, a villous-appearing mass partially prolapsed through the incision, and biopsy specimens confirmed tubulovillous adenoma with no foci of carcinoma. The pancreatitis resolved, and the patient was discharged. Subsequent EUS showed normal pancreatic duct anatomy and no intrapancreatic extension of the lesion; biopsy specimens of the limited intraductal portion of the lesion extending into the bile duct confirmed tubulovillous adenoma. Secretin MRCP revealed prominent main pancreatic duct draining into the major papilla, with suggestion of possible minimal extension of the lesion into distal bile duct (Fig. 1). The decision was made to perform endoscopic ampullectomy with treatment of any residual intraductal extension by use of argon plasma coagulation. Endoscopic ampullectomy was performed with the patient under general anesthesia. Balloon pullthrough of the common bile duct resulted in eversion of what appeared to be nodular extension of the adenoma inside the patulous sphincterotomy up the distal bile duct. The primary lesion was inferior to the bile duct in the region of the suspected pancreatic orifice. No other orifice leading
850 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 4 : 2007
www.giejournal.org
CASE REPORT
Brief Reports
Figure 1. Secretin MRCP showing prominent main pancreatic duct and possible extension of adenoma into bile duct.
Figure 2. Endoscopic view of ampullary adenoma, after biliary sphincterotomy.
Figure 3. EUS transduodenal puncture of main pancreatic duct with 19gauge needle.
Figure 4. Antegrade transpapillary passage of 0.025-inch guidewire into duodenum through EUS needle.
to the pancreatic duct could be located or cannulated, and it was decided to proceed with ampullectomy, beginning with the visible polypoid lesion (Fig. 2). A 1-cm nodule was removed with a snare by using electrocautery. Protracted attempts to locate the pancreatic orifice, including administration of intravenous secretin (70 U) and spraying topical methylene blue over the ampullectomy site were unsuccessful, with no visualization of a blush of clear pancreatic juice. Several cannulas, including 5-4-3 catheter and a hydrophilic guidewire, were used. Because of concern that the duct was thermally sealed shut, EUS was performed with the patient under the same anesthesia to access the pancreatic duct. The pancreatic duct was readily identified in the pancreatic head where it measured
5 mm in diameter. The pancreatic duct was punctured by the transduodenal route approximately 1 cm upstream from the major papilla (Fig. 3) with a 19-gauge Echotip needle (Cook, Winston-Salem, NC). A 0.025-inch guidewire was advanced through the needle and through the papilla into duodenum with fluoroscopic guidance (Fig. 4). The EUS scope was removed and the duodenoscope reinserted, and the wire was seen to be emerging from the center of the ampullectomy site. The pancreatic duct was cannulated alongside the guidewire (Fig. 5) and a 0.018inch guidewire was placed to the tail of the main pancreatic duct, followed by placement of a 5F 9-cm soft pancreatic stent to mid body of pancreatic duct, traversing the
www.giejournal.org
Volume 66, No. 4 : 2007 GASTROINTESTINAL ENDOSCOPY 851
Brief Reports
Figure 5. Retrograde cannulation of main pancreatic duct beside parallel to the antegrade guidewire placed by EUS.
Figure 6. 5F pancreatic stent placed across puncture site to mid body of pancreatic duct.
puncture site (Hobbs Medical, Stafford Springs, Conn) (Fig. 6). Resection of remaining lesion was deferred because of concern for postprocedure pancreatitis or retroperitoneal leak. The patient was admitted for observation, kept fasting, and treated with broad-spectrum antibiotics. Her postprocedure course was unremarkable. She had no significant abdominal pain, the serum amylase level the next morning was 107 IU (normal 30-110 IU), and she was discharged on a regular diet. The pancreatic stent was documented to pass within 2 weeks by abdominal x-ray examination. Pathologic study showed a tubulovillous adenoma with no high-grade dysplasia or carcinoma, with the impression that the adenoma was completely excised. However, repeat endoscopy revealed residual adenoma with intraductal extension that appeared to be more extensive than originally observed. Ultimately, the patient elected to undergo Whipple pancreaticoduodenectomy in lieu of repeated endoscopic therapy. At histopathologic examination of the resected specimen, no residual adenoma was found.
The techcnique of EUS-guided rendezvous for transpapillary duct access was first described in a single case report by Bataille in 2002 and the first series of pancreatic and biliary rendezvous by Mallery et al from our center in 2004.11 Indications for pancreatic access in those series included recurrent pancreatitis from stenotic pancreaticojejunostomy after Whipple pancreaticoduodenectomy and acute recurrent pancreatitis with pancreas divisum. To our knowledge, this is the first report of this technique in which a pancreatic stent was placed during endoscopic snare ampullectomy. This case involved a difficult decision as to whether an ag-
gressive attempt at pancreatic duct access was worthwhile. Pancreatic stent placement has been suggested to reduce the risk of post-ERCP pancreatitis and particularly to prevent severe, necrotizing pancreatitis that has occasionally been reported after endosocpic ampullectomy without a pancreatic stent.2,3,16,17 There were certain features of this case that suggested that the pancreatic orifice had been thermally sealed shut, particularly after secretin administration combined with topical methylene blue spray failed to demonstrate a blush of pancreatic juice. Such thermal injury might have resulted in either immediate acute pancreatitis, or perhaps in papillary stenosis or relapsing pancreatitis as well.16 The decision to proceed with transduodenal rendezvous EUS puncture was facilitated by previous imaging of the pancreatic duct by both EUS and secretin MRCP, demonstrating a relatively prominent duct draining through the major papilla. Alternatives to EUS drainage would have been observation; it is not possible to know whether post-ERCP pancreatitis would have developed without a stent, but if severe pancreatitis developed, later intervention and attempt at pancreatic stent placement by ERCP would have likely been impossible and of uncertain benefit even if successful. Although complications of EUS pancreatic rendezvous have not been reported, even in cases of failed pancreatic duct access,10-15 it is reasonable to assume that EUS rendezvous still carries significant potential risks. Potential morbidity would likely be similar to those associated with EUS-guided FNA and could include pancreatitis, perforation, pneumoperitoneum, infection or abscess formation, and even death.18-20 In this case, EUS rendezvous cannulation was an effective method of achieving transpapillary drainage after failed retrograde attempts after snare ampullectomy. It is not known whether aggressive pancreatic drainage as was done in this case is safer than simply not draining the pancreatic duct.
852 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 4 : 2007
www.giejournal.org
DISCUSSION
Brief Reports
However, evidence suggests that pancreatic stent placement significantly reduces the possibility of severe, necrotizing pancreatitis.1 Preampullectomy imaging of the pancreatic duct using EUS and secretin MRCP may be helpful in directing pancreatic stent placement. Preprocedure understanding of pancreatic duct anatomy will prevent uncertainty as to the reason for failure. Otherwise, when the pancreatic duct cannot be cannulated before or after ampullectomy, there is uncertainty as to whether the reason is simply failure to locate the orifice or the patient has an underlying mass, pancreas divisum with a tiny ventral pancreatic duct, or another anatomic variant. We look forward to other experiences with the EUS rendezvous technique as an adjunct to ERCP for pancreatic ductal drainage.
8.
9. 10.
11.
12.
13.
DISCLOSURE
14.
Dr Freeman has received research grants from Boston Scientific and speaking honoraria from Boston Scientific and Wilson Cook, and is an unpaid consultant to Hobbs Medical Inc. Drs Mallery and Keenan have no disclosures.
15.
16.
17.
REFERENCES 1. Singh P, Ananya D, Isenberg G, et al. Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc 2004;60:544-50. 2. Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis: a comprehensive review. Gastrointest Endosc 2004;59:845-64. 3. Catalano MF, Linder JD, Chak A, et al. Endoscopic managenment of adenoma of the major duodenal papilla. Gastrointest Endosc 2004; 59:225-32. 4. Desilets DJ, Dy RM, Ku PM, et al. Endoscopic management of tumors of the major duodenal papilla: refined techniques to improve outcome and avoid complications. Gastrointest Endosc 2001;54:202-8. 5. Harewood GC, Pochron NL, Gostout C. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 2005;62: 367-70. 6. Freeman ML, Overby CS, Qi DF. Pancreatic stent insertion: consequences of failure, and results of a modified technique to maximize success. Gastrointest Endosc 2004;59:8-14. 7. Devereaux BM, Fein S, Purich E, et al. A new synthetic porcine secretin for facilitation of cannulation of the dorsal pancreatic duct at ERCP in patients with pancreas divisum: a multicenter, random-
www.giejournal.org
18.
19.
20.
ized, double-blind comparative study. Gastrointest Endosc 2003; 57:643-7. Park SH, de Bellis M, McHenry L, et al. Use of methylene blue to identify the minor papilla or its orifice in patients with pancreas divisum. Gastrointest Endosc 2003;57:358-63. Lees WR, Heron CW. US-guided percutaneous pancretotography: experience in 75 patients. Radiology 1987;165:809-13. Bataille L, Deprez P. A new application for therapeutic EUS: main pancreatic duct drainage with a ‘‘pancreatic rendezvous technique.’’ Gastrointest Endosc 2002;55:740-3. Mallery S, Matlock J, Freeman ML. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of 6 cases. Gastrointest Endosc 2004;59:100-7. Lai R, Freeman ML. Endoscopic ultra-sound guided bile duct access for rendezvous ERCP drainage in the setting of intradiverticular papilla. Endoscopy 2005;37:487-9. Dewitt J, McHenry L, Fogel E, et al. EUS-guided methylene blue pancreatography for minor papilla localization after unsuccessful ERCP. Gastrointest Endosc 2004;59:133-6. Kahaleh M, Wang P, Shami VM, et al. EUS-guided transhepatic cholangiography: report of 6 cases. Gastrointest Endosc 2005;61:307-13. Will U, Meyer F, Manger T, et al. Endoscopic ultrasound-assisted rendezvous maneuver to achieve pancreatic duct drainage in obstructive chronic pancreatitis. Endoscopy 2005;37:171-3. Binmoeller KF, Bonaventura S, Ramsperger K, et al. Endoscopic snare excision of benign adenomas of the papilla of Vater. Gastrointest Endosc 1993;39:127-31. Norton ID, Gostout CJ, Baron TH, et al. Safety and outcome of endoscopic snare excision of the major duodenal papilla. Gastrointest Endosc 2002;56:239-43. Mergener K, Jowell PS, Branch MS, et al. Pneumoperitoneum complicating ERCP performed immediately after EUS-guided fine-needle aspiration. Gastrointest Endosc 1998;47:541-2. Wiersema MJ, Vilmann P, Giovannini M, et al. Endosonography guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment. Gastroenterology 1997;112:1087-95. Gress G, Hazar M, Gelrud D, et al. EUS-guided fine-needle aspiration of the pancreas: evaluation of pancreatitis as a complication. Gastrointest Endosc 2002;56:864-7.
Current affiliations: Division of Gastroenterology, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minn, USA. Reprint requests: Martin L. Freeman, MD, University of Minnesota, Division of Gastroenterology, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.01.005
Volume 66, No. 4 : 2007 GASTROINTESTINAL ENDOSCOPY 853
In our report we have tried to emphasize the special circumstances in this case, that is, a trifistula, and the novel therapeutic approach taken. DISCLOSURE None of the authors have anything to disclose. Abbreviations: ALP, alkaline phosphatase; ALT, alanine aminotransferase; CBD, common bile duct.
3. Sandblom P, Jakobsson B, Lindgren H, et al. Fatal bilhemia. Surgery 2000;127:354-7. 4. Glaser K, Wetscher G, Pointner R, et al. Traumatic bilhemia. Surgery 1994;116:24-7. 5. Lee D, Chitturi S, Kench J, et al. Transjugular liver biopsy effecting changes in clinical management. Aust Radiol 2003;47:117-20.
Division of Gastroenterology-Hepatology, Department of Internal Medicine (O.M.B.), Department of Radiology (S.S.), Department of Pathology (J.W.), University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA.
REFERENCES
Reprint requests: William Silverman, MD, Division of Gastroenterology-Hepatology, 200 Hawkins Dr, 4553 JCP, Iowa City, IA 52242.
1. Brown CY, Walsh GC. Fatal bile embolism following liver biopsy. Ann Intern Med 1952;36:1529-33. 2. Clemens M, Wittrin G. Bilha¨mie und ha¨mobilie nach Reitunfall, Vortag 166. Hamburg: Tagung Nordwestdeutscher Chirurgen; 1975.
Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.01.027
EUS rendezvous for pancreatic stent placement during endoscopic snare ampullectomy Joseph Keenan, MD, Shawn Mallery, MD, Martin L. Freeman, MD Minneapolis, Minnesota, USA
Placement of transpapillary pancreatic stents has been shown to decrease the risk of post-ERCP pancreatitis in a number of high-risk settings.1,2 Pancreatic stent placement is considered to be particularly important after endoscopic ampullectomy.3-5 However, even in the most experienced hands, pancreatic cannulation and stent placement are not always successful.6 Failure may be the result of atypical anatomy, pancreatic duct obstruction, edema, tumor infiltration, postoperative changes, or cautery artifact after endoscopic ampullectomy. Avariety of techniques have been used to facilitate difficult retrograde pancreatic duct cannulation, including administration of secretin,7 spraying methylene blue on the surface of the papilla,8 and even percutaneous ductal access.9 Recently, the technique of EUS-guided rendezvous pancreatic and bile duct access has been described.10-15 By accessing a pancreatic or bile duct by the transgastric or transduodenal route, a guidewire is placed anterograde through the ampulla, thereby aiding retrograde cannulation by ERCP. The current case describes the first reported to our knowledge of the use of EUS rendezvous for pancreatic stent placement during endoscopic snare ampullectomy.
A 71-year-old woman who was remotely post cholecystectomy was seen for acute pancreatitis of suspected biliary
etiology, with findings of abnormal liver chemistries and a dilated bile duct at transabdominal US. Initial ERCP demonstrated a prominent ampulla without obvious neoplastic transformation. Neither the pancreatic nor bile ducts could be initially cannulated; therefore, a precut ‘‘fistulotomy’’ was performed and biliary sphincterotomy completed. After sphincterotomy, a villous-appearing mass partially prolapsed through the incision, and biopsy specimens confirmed tubulovillous adenoma with no foci of carcinoma. The pancreatitis resolved, and the patient was discharged. Subsequent EUS showed normal pancreatic duct anatomy and no intrapancreatic extension of the lesion; biopsy specimens of the limited intraductal portion of the lesion extending into the bile duct confirmed tubulovillous adenoma. Secretin MRCP revealed prominent main pancreatic duct draining into the major papilla, with suggestion of possible minimal extension of the lesion into distal bile duct (Fig. 1). The decision was made to perform endoscopic ampullectomy with treatment of any residual intraductal extension by use of argon plasma coagulation. Endoscopic ampullectomy was performed with the patient under general anesthesia. Balloon pullthrough of the common bile duct resulted in eversion of what appeared to be nodular extension of the adenoma inside the patulous sphincterotomy up the distal bile duct. The primary lesion was inferior to the bile duct in the region of the suspected pancreatic orifice. No other orifice leading
850 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 4 : 2007
www.giejournal.org
CASE REPORT
Brief Reports
Figure 1. Secretin MRCP showing prominent main pancreatic duct and possible extension of adenoma into bile duct.
Figure 2. Endoscopic view of ampullary adenoma, after biliary sphincterotomy.
Figure 3. EUS transduodenal puncture of main pancreatic duct with 19gauge needle.
Figure 4. Antegrade transpapillary passage of 0.025-inch guidewire into duodenum through EUS needle.
to the pancreatic duct could be located or cannulated, and it was decided to proceed with ampullectomy, beginning with the visible polypoid lesion (Fig. 2). A 1-cm nodule was removed with a snare by using electrocautery. Protracted attempts to locate the pancreatic orifice, including administration of intravenous secretin (70 U) and spraying topical methylene blue over the ampullectomy site were unsuccessful, with no visualization of a blush of clear pancreatic juice. Several cannulas, including 5-4-3 catheter and a hydrophilic guidewire, were used. Because of concern that the duct was thermally sealed shut, EUS was performed with the patient under the same anesthesia to access the pancreatic duct. The pancreatic duct was readily identified in the pancreatic head where it measured
5 mm in diameter. The pancreatic duct was punctured by the transduodenal route approximately 1 cm upstream from the major papilla (Fig. 3) with a 19-gauge Echotip needle (Cook, Winston-Salem, NC). A 0.025-inch guidewire was advanced through the needle and through the papilla into duodenum with fluoroscopic guidance (Fig. 4). The EUS scope was removed and the duodenoscope reinserted, and the wire was seen to be emerging from the center of the ampullectomy site. The pancreatic duct was cannulated alongside the guidewire (Fig. 5) and a 0.018inch guidewire was placed to the tail of the main pancreatic duct, followed by placement of a 5F 9-cm soft pancreatic stent to mid body of pancreatic duct, traversing the
www.giejournal.org
Volume 66, No. 4 : 2007 GASTROINTESTINAL ENDOSCOPY 851
Brief Reports
Figure 5. Retrograde cannulation of main pancreatic duct beside parallel to the antegrade guidewire placed by EUS.
Figure 6. 5F pancreatic stent placed across puncture site to mid body of pancreatic duct.
puncture site (Hobbs Medical, Stafford Springs, Conn) (Fig. 6). Resection of remaining lesion was deferred because of concern for postprocedure pancreatitis or retroperitoneal leak. The patient was admitted for observation, kept fasting, and treated with broad-spectrum antibiotics. Her postprocedure course was unremarkable. She had no significant abdominal pain, the serum amylase level the next morning was 107 IU (normal 30-110 IU), and she was discharged on a regular diet. The pancreatic stent was documented to pass within 2 weeks by abdominal x-ray examination. Pathologic study showed a tubulovillous adenoma with no high-grade dysplasia or carcinoma, with the impression that the adenoma was completely excised. However, repeat endoscopy revealed residual adenoma with intraductal extension that appeared to be more extensive than originally observed. Ultimately, the patient elected to undergo Whipple pancreaticoduodenectomy in lieu of repeated endoscopic therapy. At histopathologic examination of the resected specimen, no residual adenoma was found.
The techcnique of EUS-guided rendezvous for transpapillary duct access was first described in a single case report by Bataille in 2002 and the first series of pancreatic and biliary rendezvous by Mallery et al from our center in 2004.11 Indications for pancreatic access in those series included recurrent pancreatitis from stenotic pancreaticojejunostomy after Whipple pancreaticoduodenectomy and acute recurrent pancreatitis with pancreas divisum. To our knowledge, this is the first report of this technique in which a pancreatic stent was placed during endoscopic snare ampullectomy. This case involved a difficult decision as to whether an ag-
gressive attempt at pancreatic duct access was worthwhile. Pancreatic stent placement has been suggested to reduce the risk of post-ERCP pancreatitis and particularly to prevent severe, necrotizing pancreatitis that has occasionally been reported after endosocpic ampullectomy without a pancreatic stent.2,3,16,17 There were certain features of this case that suggested that the pancreatic orifice had been thermally sealed shut, particularly after secretin administration combined with topical methylene blue spray failed to demonstrate a blush of pancreatic juice. Such thermal injury might have resulted in either immediate acute pancreatitis, or perhaps in papillary stenosis or relapsing pancreatitis as well.16 The decision to proceed with transduodenal rendezvous EUS puncture was facilitated by previous imaging of the pancreatic duct by both EUS and secretin MRCP, demonstrating a relatively prominent duct draining through the major papilla. Alternatives to EUS drainage would have been observation; it is not possible to know whether post-ERCP pancreatitis would have developed without a stent, but if severe pancreatitis developed, later intervention and attempt at pancreatic stent placement by ERCP would have likely been impossible and of uncertain benefit even if successful. Although complications of EUS pancreatic rendezvous have not been reported, even in cases of failed pancreatic duct access,10-15 it is reasonable to assume that EUS rendezvous still carries significant potential risks. Potential morbidity would likely be similar to those associated with EUS-guided FNA and could include pancreatitis, perforation, pneumoperitoneum, infection or abscess formation, and even death.18-20 In this case, EUS rendezvous cannulation was an effective method of achieving transpapillary drainage after failed retrograde attempts after snare ampullectomy. It is not known whether aggressive pancreatic drainage as was done in this case is safer than simply not draining the pancreatic duct.
852 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 4 : 2007
www.giejournal.org
DISCUSSION
Brief Reports
However, evidence suggests that pancreatic stent placement significantly reduces the possibility of severe, necrotizing pancreatitis.1 Preampullectomy imaging of the pancreatic duct using EUS and secretin MRCP may be helpful in directing pancreatic stent placement. Preprocedure understanding of pancreatic duct anatomy will prevent uncertainty as to the reason for failure. Otherwise, when the pancreatic duct cannot be cannulated before or after ampullectomy, there is uncertainty as to whether the reason is simply failure to locate the orifice or the patient has an underlying mass, pancreas divisum with a tiny ventral pancreatic duct, or another anatomic variant. We look forward to other experiences with the EUS rendezvous technique as an adjunct to ERCP for pancreatic ductal drainage.
8.
9. 10.
11.
12.
13.
DISCLOSURE
14.
Dr Freeman has received research grants from Boston Scientific and speaking honoraria from Boston Scientific and Wilson Cook, and is an unpaid consultant to Hobbs Medical Inc. Drs Mallery and Keenan have no disclosures.
15.
16.
17.
REFERENCES 1. Singh P, Ananya D, Isenberg G, et al. Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc 2004;60:544-50. 2. Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis: a comprehensive review. Gastrointest Endosc 2004;59:845-64. 3. Catalano MF, Linder JD, Chak A, et al. Endoscopic managenment of adenoma of the major duodenal papilla. Gastrointest Endosc 2004; 59:225-32. 4. Desilets DJ, Dy RM, Ku PM, et al. Endoscopic management of tumors of the major duodenal papilla: refined techniques to improve outcome and avoid complications. Gastrointest Endosc 2001;54:202-8. 5. Harewood GC, Pochron NL, Gostout C. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 2005;62: 367-70. 6. Freeman ML, Overby CS, Qi DF. Pancreatic stent insertion: consequences of failure, and results of a modified technique to maximize success. Gastrointest Endosc 2004;59:8-14. 7. Devereaux BM, Fein S, Purich E, et al. A new synthetic porcine secretin for facilitation of cannulation of the dorsal pancreatic duct at ERCP in patients with pancreas divisum: a multicenter, random-
www.giejournal.org
18.
19.
20.
ized, double-blind comparative study. Gastrointest Endosc 2003; 57:643-7. Park SH, de Bellis M, McHenry L, et al. Use of methylene blue to identify the minor papilla or its orifice in patients with pancreas divisum. Gastrointest Endosc 2003;57:358-63. Lees WR, Heron CW. US-guided percutaneous pancretotography: experience in 75 patients. Radiology 1987;165:809-13. Bataille L, Deprez P. A new application for therapeutic EUS: main pancreatic duct drainage with a ‘‘pancreatic rendezvous technique.’’ Gastrointest Endosc 2002;55:740-3. Mallery S, Matlock J, Freeman ML. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of 6 cases. Gastrointest Endosc 2004;59:100-7. Lai R, Freeman ML. Endoscopic ultra-sound guided bile duct access for rendezvous ERCP drainage in the setting of intradiverticular papilla. Endoscopy 2005;37:487-9. Dewitt J, McHenry L, Fogel E, et al. EUS-guided methylene blue pancreatography for minor papilla localization after unsuccessful ERCP. Gastrointest Endosc 2004;59:133-6. Kahaleh M, Wang P, Shami VM, et al. EUS-guided transhepatic cholangiography: report of 6 cases. Gastrointest Endosc 2005;61:307-13. Will U, Meyer F, Manger T, et al. Endoscopic ultrasound-assisted rendezvous maneuver to achieve pancreatic duct drainage in obstructive chronic pancreatitis. Endoscopy 2005;37:171-3. Binmoeller KF, Bonaventura S, Ramsperger K, et al. Endoscopic snare excision of benign adenomas of the papilla of Vater. Gastrointest Endosc 1993;39:127-31. Norton ID, Gostout CJ, Baron TH, et al. Safety and outcome of endoscopic snare excision of the major duodenal papilla. Gastrointest Endosc 2002;56:239-43. Mergener K, Jowell PS, Branch MS, et al. Pneumoperitoneum complicating ERCP performed immediately after EUS-guided fine-needle aspiration. Gastrointest Endosc 1998;47:541-2. Wiersema MJ, Vilmann P, Giovannini M, et al. Endosonography guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment. Gastroenterology 1997;112:1087-95. Gress G, Hazar M, Gelrud D, et al. EUS-guided fine-needle aspiration of the pancreas: evaluation of pancreatitis as a complication. Gastrointest Endosc 2002;56:864-7.
Current affiliations: Division of Gastroenterology, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minn, USA. Reprint requests: Martin L. Freeman, MD, University of Minnesota, Division of Gastroenterology, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.01.005
Volume 66, No. 4 : 2007 GASTROINTESTINAL ENDOSCOPY 853