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Review of EUS-guided pancreatic duct drainage (with video)
Review of EUS-guided pancreatic duct drainage (with video) Shyam Varadarajulu, MD, Jessica M. Trevino, MD Birmingham, Alabama, USA
EUS-GUIDED PANCREATIC-DUCT DRAINAGE It is postulated that abdominal pain in chronic pancreatitis results from obstruction to the flow of pancreatic juice, which causes pancreatic-duct hypertension and increased pancreatic parenchymal pressure. ERCP is considered by most experts to be the first-line treatment modality for management of obstructive chronic pancreatitis, given its high rate of technical success, low rate of procedural morbidity, and the minimally invasive nature of the technique. Surgery is recommended when ERCP is technically unsuccessful or if endotherapy fails for the patient or when repeated interventions are warranted. Recently, for patients with an obstructive main pancreatic duct from chronic pancreatitis and other benign causes, EUS has been advocated as an alternative treatment measure when ERCP is unsuccessful. The objective of this review is to (1) outline the rationale for EUS-guided pancreatic-duct drainage, (2) detail the procedural technique, and (3) evaluate the clinical outcomes and limitations of the technique.
RATIONALE FOR EUS-GUIDED DRAINAGE OF THE MAIN PANCREATIC DUCT Technical failure at ERCP is encountered when the papilla cannot be reached or identified, as in patients with altered surgical anatomy or when the main pancreatic duct cannot be cannulated because of the presence of a tight stricture, occlusive stone, complete disruption, severe inflammation, or a stenotic orifice in the setting of pancreas divisum.1 Traditionally, these patients are managed by surgery or conservative measures. The type of surgery is based on the clinical presentation and anatomy of the pancreatic-ductal system.2 In patients with a dilated main pancreatic duct, a Puestow procedure (lateral pancreaticojejunostomy) is undertaken to drain the duct. In patients with focal disease, a resection procedure, such as a Whipple procedure or distal pancreatectomy, is undertaken. However, 20% of patients undergoing a drainage procedure develop recurrent symptoms within a few years, and 5% of patients undergoing a Whipple proce-
DISCLOSURE: S. Varadarajulu and J. M. Trevino disclosed no financial relationships relevant to this publication. Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2008.12.032
S200 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
dure develop anastomotic strictures.3,4 A substantial proportion of patients with chronic pancreatitis have coexisting portal hypertension and other comorbidities, which makes them high-risk surgical candidates.5 Therefore, EUS-guided drainage of the main pancreatic duct may be an effective treatment option for those patients in whom ERCP is technically unsuccessful and who are high-risk surgical candidates.
PROCEDURAL TECHNIQUE EUS-guided drainage of the main pancreatic duct can be undertaken either by a transluminal approach (via the stomach or the duodenum) or by the rendezvous transpapillary approach.
Transluminal approach The therapeutic curvilinear echoendoscope is positioned in the stomach or the duodenal bulb and, after excluding the presence of intervening vasculature, the main pancreatic duct is punctured by using a 19-gauge or 22-gauge FNA needle (Fig. 1A). Once the needle is seen within the main pancreatic duct at EUS, contrast medium is injected to obtain a pancreatogram. A 0.035-inch or 0.020-inch guidewire is passed via the FNA needle into the main pancreatic duct, preferably in an antegrade direction into the duodenum. If this orientation cannot be accomplished, then the guidewire is advanced retrograde to the pancreatic tail region (Fig. 1B). The transmural tract is then dilated by using small bougies, 4.5F ERCP cannula, or by administration of electrocautery by using a diathermic sheath. After further dilation by using small caliber (4-6 mm) balloons, a 7F stent of appropriate length is deployed via the stomach or the duodenum into the main pancreatic duct.
Transpapillary rendezvous approach A rendezvous technique is feasible only when the duodenoscope or colonoscope can be advanced to the papillary orifice or to the site of surgical anastomosis for retrieval of the guidewire to undertake subsequent therapy. After puncturing the main pancreatic duct, the guidewire is then advanced antegrade under fluoroscopic guidance into the small bowel via the papillary orifice (Video 1, available online at www.giejournal.org). The echoendoscope is then withdrawn, and the duodenoscope or the colonoscope is passed so that the papilla or the anastomotic site can then be cannulated alongside the guidewire or by retrieving the guidewire into the www.giejournal.org
Varadarajulu & Trevino
EUS-guided pancreatogastrostomy
Figure 1. A, The pancreatic duct was accessed with a 19-gauge FNA needle under EUS guidance in a patient with chronic pancreatitis and altered anatomy. B, EUS-guided pancreatogram with retrograde passage of a guidewire; pancreatic stricture precluded antegrade passage of the guidewire. Note the acute angle at which the pancreatic duct was accessed at EUS. Stenting was unsuccessful in this patient because of technical difficulty with transmural dilation. C, A gross specimen reveals a thick fibrotic gland. A surgical drainage procedure was unsuccessful because of severe glandular fibrosis. The patient underwent a total pancreatectomy with islet cell transplantation.
TABLE 1. Major series that evaluated EUS-guided drainage of the main pancreatic duct
Study
Design 6
Tessier et al, 2007
Approach
No. cases
Technical success (%)
Treatment success (%)*
Complications (%)*
Retrospective
Transluminal
36
91.6
69
5.5
Kahaleh et al, 2007
Prospective
Transluminal
13
83
68
15.4
8
Will et al, 2007
Case series
Transluminal and rendezvous
12
69
71.4
42.9
Mallery et al,9 2004
Case series
Rendezvous
4
25
25
25
7
*Treatment success and complications were evaluated on the basis of intention to treat.
www.giejournal.org
Volume 69, No. 2 : 2009 GASTROINTESTINAL ENDOSCOPY S201
EUS-guided pancreatogastrostomy
working channel of the endoscope for performing further endotherapy.
CLINICAL OUTCOMES Four series6-9 evaluated the outcomes of EUS-guided drainage of the main pancreatic duct (Table 1). Technical failures were mainly because of difficulty in orienting the echoendoscope along the axis of the main pancreatic duct, the inability to dilate the transmural tract because of dense fibrosis, and difficulty with endotherapy because of the acute angle at which the pancreatic duct was accessed at EUS. As with most studies in the ERCP literature, medium-term pain relief was experienced by 60% to 70% of patients after pancreatic stenting. Stent migration and/or occlusion were reported in 20% to 55% of cases drained transluminally.6,8 The rate of procedural complications in the 4 series varied between 5% and 43%, and included perforation, hemorrhage, pancreatitis, fever, and postprocedural pain.
PROCEDURAL LIMITATIONS EUS-guided drainage can be attempted only when the main pancreatic is dilated and when the echoendoscope can be oriented correctly along the axis of the main pancreatic duct. Placement of stents and other endotherapy may be technically challenging because of the acute angle in which the pancreatic duct is accessed at EUS (Fig. 1B). Severe parenchymal fibrosis may preclude ductal access, because dilation of the transmural tract can be technically difficult (Fig. 1C). Procedural complications reported in the current series are major, and the rates of adverse events are high.
CONCLUSIONS There certainly exists a role for EUS in the management of a subset of patients with chronic pancreatitis who fail ERCP and are high-risk surgical candidates. However, the technical success rate appears to be modest, even at expert centers, and the rates of procedural complications are high. A dedicated MRCP must be obtained and surgical
S202 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
Varadarajulu & Trevino
input should be sought before EUS-guided pancreaticduct drainage in all patients. More studies with larger numbers of patients are required to evaluate the best technique (transluminal vs rendezvous approach), safety, and long-term clinical implications of the procedure. Further refinements in techniques to minimize the high rate of procedural complications are required. Until these issues are resolved, EUS-guided pancreatic-duct drainages should be undertaken only at tertiary-care centers under a research protocol.
REFERENCES 1. Gupta K, Mallery S, Hunter D, et al. Endoscopic ultrasound and percutaneous access for endoscopic biliary and pancreatic drainage after initially failed ERCP. Rev Gastroenterol Disord 2007;7: 22-37. 2. Varadarajulu S, Hawes RH. Chronic pancreatitis, stones, and strictures. In: Ginsberg GG, Kochman ML, Norton I, et al, editors. Clinical gastrointestinal endoscopy. Philadelphia: Elsevier; 2005. p. 785-805. 3. Adams DB, Ford MC, Anderson MC. Outcomes after lateral pancreaticojejunostomy for chronic pancreatitis. Ann Surg 1994;219:481-7. 4. Reid-Lombardo KM, Ramos-De la Medina A, Thomsen K, et al. Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases. J Gastrointest Surg 2007;11:1704-11. 5. Alexakis N, Sutton R, Raraty M, et al. Major resection for chronic pancreatitis in patients with vascular involvement is associated with increased postoperative mortality. Br J Surg 2004;91:1020-6. 6. Tessier G, Bories E, Arvanitakis M, et al. EUS-guided pancreatogastrostomy and pancreatobulbostomy for the treatment of pain in patients with pancreatic ductal dilatation inaccessible for transpapillary endoscopic therapy. Gastrointest Endosc 2007;65:233-41. 7. Kahaleh M, Hernandez AJ, Tokar J, et al. EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts. Gastrointest Endosc 2007;65:224-30. 8. Will U, Fueldner F, Thieme A-K, et al. Transgastric pancreatography and EUS-guided drainage of the pancreatic duct. J Hepatobiliary Pancreat Surg 2007;14:377-82. 9. 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.
Division of Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA. This article is from a meeting and has not undergone the GIE peer review process.
www.giejournal.org
EUS-GUIDED PANCREATIC-DUCT DRAINAGE It is postulated that abdominal pain in chronic pancreatitis results from obstruction to the flow of pancreatic juice, which causes pancreatic-duct hypertension and increased pancreatic parenchymal pressure. ERCP is considered by most experts to be the first-line treatment modality for management of obstructive chronic pancreatitis, given its high rate of technical success, low rate of procedural morbidity, and the minimally invasive nature of the technique. Surgery is recommended when ERCP is technically unsuccessful or if endotherapy fails for the patient or when repeated interventions are warranted. Recently, for patients with an obstructive main pancreatic duct from chronic pancreatitis and other benign causes, EUS has been advocated as an alternative treatment measure when ERCP is unsuccessful. The objective of this review is to (1) outline the rationale for EUS-guided pancreatic-duct drainage, (2) detail the procedural technique, and (3) evaluate the clinical outcomes and limitations of the technique.
RATIONALE FOR EUS-GUIDED DRAINAGE OF THE MAIN PANCREATIC DUCT Technical failure at ERCP is encountered when the papilla cannot be reached or identified, as in patients with altered surgical anatomy or when the main pancreatic duct cannot be cannulated because of the presence of a tight stricture, occlusive stone, complete disruption, severe inflammation, or a stenotic orifice in the setting of pancreas divisum.1 Traditionally, these patients are managed by surgery or conservative measures. The type of surgery is based on the clinical presentation and anatomy of the pancreatic-ductal system.2 In patients with a dilated main pancreatic duct, a Puestow procedure (lateral pancreaticojejunostomy) is undertaken to drain the duct. In patients with focal disease, a resection procedure, such as a Whipple procedure or distal pancreatectomy, is undertaken. However, 20% of patients undergoing a drainage procedure develop recurrent symptoms within a few years, and 5% of patients undergoing a Whipple proce-
DISCLOSURE: S. Varadarajulu and J. M. Trevino disclosed no financial relationships relevant to this publication. Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2008.12.032
S200 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
dure develop anastomotic strictures.3,4 A substantial proportion of patients with chronic pancreatitis have coexisting portal hypertension and other comorbidities, which makes them high-risk surgical candidates.5 Therefore, EUS-guided drainage of the main pancreatic duct may be an effective treatment option for those patients in whom ERCP is technically unsuccessful and who are high-risk surgical candidates.
PROCEDURAL TECHNIQUE EUS-guided drainage of the main pancreatic duct can be undertaken either by a transluminal approach (via the stomach or the duodenum) or by the rendezvous transpapillary approach.
Transluminal approach The therapeutic curvilinear echoendoscope is positioned in the stomach or the duodenal bulb and, after excluding the presence of intervening vasculature, the main pancreatic duct is punctured by using a 19-gauge or 22-gauge FNA needle (Fig. 1A). Once the needle is seen within the main pancreatic duct at EUS, contrast medium is injected to obtain a pancreatogram. A 0.035-inch or 0.020-inch guidewire is passed via the FNA needle into the main pancreatic duct, preferably in an antegrade direction into the duodenum. If this orientation cannot be accomplished, then the guidewire is advanced retrograde to the pancreatic tail region (Fig. 1B). The transmural tract is then dilated by using small bougies, 4.5F ERCP cannula, or by administration of electrocautery by using a diathermic sheath. After further dilation by using small caliber (4-6 mm) balloons, a 7F stent of appropriate length is deployed via the stomach or the duodenum into the main pancreatic duct.
Transpapillary rendezvous approach A rendezvous technique is feasible only when the duodenoscope or colonoscope can be advanced to the papillary orifice or to the site of surgical anastomosis for retrieval of the guidewire to undertake subsequent therapy. After puncturing the main pancreatic duct, the guidewire is then advanced antegrade under fluoroscopic guidance into the small bowel via the papillary orifice (Video 1, available online at www.giejournal.org). The echoendoscope is then withdrawn, and the duodenoscope or the colonoscope is passed so that the papilla or the anastomotic site can then be cannulated alongside the guidewire or by retrieving the guidewire into the www.giejournal.org
Varadarajulu & Trevino
EUS-guided pancreatogastrostomy
Figure 1. A, The pancreatic duct was accessed with a 19-gauge FNA needle under EUS guidance in a patient with chronic pancreatitis and altered anatomy. B, EUS-guided pancreatogram with retrograde passage of a guidewire; pancreatic stricture precluded antegrade passage of the guidewire. Note the acute angle at which the pancreatic duct was accessed at EUS. Stenting was unsuccessful in this patient because of technical difficulty with transmural dilation. C, A gross specimen reveals a thick fibrotic gland. A surgical drainage procedure was unsuccessful because of severe glandular fibrosis. The patient underwent a total pancreatectomy with islet cell transplantation.
TABLE 1. Major series that evaluated EUS-guided drainage of the main pancreatic duct
Study
Design 6
Tessier et al, 2007
Approach
No. cases
Technical success (%)
Treatment success (%)*
Complications (%)*
Retrospective
Transluminal
36
91.6
69
5.5
Kahaleh et al, 2007
Prospective
Transluminal
13
83
68
15.4
8
Will et al, 2007
Case series
Transluminal and rendezvous
12
69
71.4
42.9
Mallery et al,9 2004
Case series
Rendezvous
4
25
25
25
7
*Treatment success and complications were evaluated on the basis of intention to treat.
www.giejournal.org
Volume 69, No. 2 : 2009 GASTROINTESTINAL ENDOSCOPY S201
EUS-guided pancreatogastrostomy
working channel of the endoscope for performing further endotherapy.
CLINICAL OUTCOMES Four series6-9 evaluated the outcomes of EUS-guided drainage of the main pancreatic duct (Table 1). Technical failures were mainly because of difficulty in orienting the echoendoscope along the axis of the main pancreatic duct, the inability to dilate the transmural tract because of dense fibrosis, and difficulty with endotherapy because of the acute angle at which the pancreatic duct was accessed at EUS. As with most studies in the ERCP literature, medium-term pain relief was experienced by 60% to 70% of patients after pancreatic stenting. Stent migration and/or occlusion were reported in 20% to 55% of cases drained transluminally.6,8 The rate of procedural complications in the 4 series varied between 5% and 43%, and included perforation, hemorrhage, pancreatitis, fever, and postprocedural pain.
PROCEDURAL LIMITATIONS EUS-guided drainage can be attempted only when the main pancreatic is dilated and when the echoendoscope can be oriented correctly along the axis of the main pancreatic duct. Placement of stents and other endotherapy may be technically challenging because of the acute angle in which the pancreatic duct is accessed at EUS (Fig. 1B). Severe parenchymal fibrosis may preclude ductal access, because dilation of the transmural tract can be technically difficult (Fig. 1C). Procedural complications reported in the current series are major, and the rates of adverse events are high.
CONCLUSIONS There certainly exists a role for EUS in the management of a subset of patients with chronic pancreatitis who fail ERCP and are high-risk surgical candidates. However, the technical success rate appears to be modest, even at expert centers, and the rates of procedural complications are high. A dedicated MRCP must be obtained and surgical
S202 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
Varadarajulu & Trevino
input should be sought before EUS-guided pancreaticduct drainage in all patients. More studies with larger numbers of patients are required to evaluate the best technique (transluminal vs rendezvous approach), safety, and long-term clinical implications of the procedure. Further refinements in techniques to minimize the high rate of procedural complications are required. Until these issues are resolved, EUS-guided pancreatic-duct drainages should be undertaken only at tertiary-care centers under a research protocol.
REFERENCES 1. Gupta K, Mallery S, Hunter D, et al. Endoscopic ultrasound and percutaneous access for endoscopic biliary and pancreatic drainage after initially failed ERCP. Rev Gastroenterol Disord 2007;7: 22-37. 2. Varadarajulu S, Hawes RH. Chronic pancreatitis, stones, and strictures. In: Ginsberg GG, Kochman ML, Norton I, et al, editors. Clinical gastrointestinal endoscopy. Philadelphia: Elsevier; 2005. p. 785-805. 3. Adams DB, Ford MC, Anderson MC. Outcomes after lateral pancreaticojejunostomy for chronic pancreatitis. Ann Surg 1994;219:481-7. 4. Reid-Lombardo KM, Ramos-De la Medina A, Thomsen K, et al. Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases. J Gastrointest Surg 2007;11:1704-11. 5. Alexakis N, Sutton R, Raraty M, et al. Major resection for chronic pancreatitis in patients with vascular involvement is associated with increased postoperative mortality. Br J Surg 2004;91:1020-6. 6. Tessier G, Bories E, Arvanitakis M, et al. EUS-guided pancreatogastrostomy and pancreatobulbostomy for the treatment of pain in patients with pancreatic ductal dilatation inaccessible for transpapillary endoscopic therapy. Gastrointest Endosc 2007;65:233-41. 7. Kahaleh M, Hernandez AJ, Tokar J, et al. EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts. Gastrointest Endosc 2007;65:224-30. 8. Will U, Fueldner F, Thieme A-K, et al. Transgastric pancreatography and EUS-guided drainage of the pancreatic duct. J Hepatobiliary Pancreat Surg 2007;14:377-82. 9. 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.
Division of Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA. This article is from a meeting and has not undergone the GIE peer review process.
www.giejournal.org