Endoscopic Ultrasound-Guided Pancreatic Transmural Stenting and Transmural Intervention

Abstract

Endoscopic ultrasound (EUS)-guided pancreatic access is an emergent method that can be divided into the two main techniques of EUS-guided rendezvous and pancreatic transmural stenting (PTS). While many reports have described EUS-guided procedures, the indications, technical tips, clinical effects, and safety of EUS-guided pancreatic duct drainage (EUS-PD) remain controversial. This review describes the current status of and problems associated with EUS-PD, particularly PTS. We reviewed clinical data derived from a total of 334 patients. Rates of technical and clinical success ranged from 63% to 100% and 76% to 100%, respectively. In contrast, the rate of procedure-related adverse events was high at 26.7% (89/334). The most frequent adverse events comprised abdominal pain (n=38), acute pancreatitis (n=15), bleeding (n=9), and issues associated with pancreatic juice leakage such as perigastric fluid, pancreatic fluid collection, or pancreatic juice leaks (n=8). In conclusion, indications for EUS-PTS are limited, as is the evidence of its viability, due to the scarcity of expert operators. Despite improvements made to various devices, EUS-PTS remains technically challenging. Therefore, a long-term, large-scale, multicenter study is required to establish this technique as a viable alternative drainage method. Clin Endosc 2020;53:429-435

Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: Techniques and Literature Review of Transmural Stenting

“…A transduodenal approach from the "long position" might allow a better view of the MPD for puncture than the transgastric approach. 3,13 Moreover, intraoperative stability and ease of pushing the stent were also reported as advantages associated with the transduodenal approach. However, in a transduodenal puncture, it might be difficult to pass through the stenosis of the guidewire when the stenosis is in the pancreatic body.…”

“…In addition, care should be taken for the gastroduodenal artery running near the puncture route from the duodenal bulb, as it can be injured due to the burning effects of electrocautery dilation. 13 Although previous reports seem to indicate that there is currently no difference in the technical and clinical perspectives by either route, a substantial number of available studies had selected the transgastric route. Overall, both transgastric and transduodenal routes are acceptable, but it is better to attempt puncturing from a site with better conditions.…”

“…Originally, transmural plastic stent deployment for EUS-PD might have had lesser migration into the abdominal cavity than EUS-guided hepaticogastrostomy because the pancreas and the gastric wall are in close contact. 13 Particularly in cases in which the PD is not very dilated, plastic stents are more suitable than metallic stents. The rates of technical success and adverse events of EUS-PTS using plastic stents were reported to range from 80.9% to 100% and from 12.5% to 26.7%, respectively.…”

“…17 A large diameter FCSEMS might have the advantage of effective drainage and easy re-intervention compared to plastic stents. 13 In addition, the tamponade effect of FCSEMS may prevent pancreatic juice leakage and reduce the bleeding risk associated with electrocautery tract dilation. Moreover, FCSEMS may provide extended stent patency, fewer repeat interventions, and shorter hospital stays.…”

Technical tips for endoscopic ultrasound-guided pancreatic duct access and drainage

“…EUS-guided pancreatic duct drainage (EUS-PD) is indicated for pancreatic duct obstruction, pancreatic leakage and disconnected pancreatic duct syndrome after failed or difficult ERCP. [1][2][3][4] Recently, there are some technical updates for EUS-PD and in this review, we would like to focus on the technical issues of EUS-guided interventions for pancreatic diseases.…”