Endoscopic endgame for obstructive pancreatopathy: outcomes of anterograde EUS-guided pancreatic duct drainage. A dual-center study

      Background and Aims

      Anterograde endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) refers to transmural drainage of the main pancreatic duct via an endoprosthesis passed anterograde through the gastric (or intestinal) wall. Anterograde EUS-PDD is a rescue procedure for recalcitrant cases of benign obstructive pancreatopathy.

      Methods

      We conducted a dual-center retrospective chart review of 28 patients (mean age, 59 years; 50% female) who underwent attempted anterograde EUS-PDD between April 2016 and September 2019 for chronic pancreatitis (CP) (93%) or pancreaticojejunostomy stenosis (PJS) after Whipple resection (7%). The study endpoint was achievement of transpapillary/transanastomotic drainage (definitive therapy).

      Results

      Gastropancreaticoenterostomy (ring drainage, definitive therapy) was successfully performed during the index procedure in the 2 patients with PJS (technical success, 100%). Clinical success was 100% in the 2 ring drainage recipients during a mean 18-month follow-up period. The remaining 26 patients with CP underwent attempted pancreaticogastrostomy (PG) with 81% technical success, 75% clinical success, and 15% adverse events (AEs). Repeat endoscopic transmural interventions were performed in the 15 patients with clinical success after PG creation. Definitive therapy transpired in all 15 patients after a median 1 repeat procedure per patient. Clinical success after definitive therapy was maintained in all 15 patients (100%) during a median 4.5-month follow-up.

      Conclusions

      In agreement with previous studies, our study showed mild to moderately high rates of technical failure (19%), clinical failure (25%), and AEs (15%) during index drainage (PG creation). Among patients with CP with both technical and clinical success after index PG creation (n = 15), 100% definitive therapy was achieved and clinical outcomes were excellent (100% clinical success, 0% AEs).

      Graphical abstract

      Abbreviations:

      AE (adverse event), CP (chronic pancreatitis), EA-ERP (enteroscopy-assisted endoscopic retrograde pancreatography), ECE-LAMS (electrocautery-enhanced lumen-apposing metal stent), ERP (endoscopic retrograde pancreatography), EUS-PDD (endoscopic ultrasound-guided pancreatic duct drainage), IQR (interquartile range), MPD (main pancreatic duct), PG (pancreaticogastrostomy), PJS (pancreaticojejunostomy stenosis), TMP-EHL (transmural (anterograde) pancreatoscopy with electrohydraulic lithotripsy)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Löhr J.M.
        • Dominguez-Munoz E.
        • Rosendahl J.
        • et al.
        United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU).
        United European Gastroenterol J. 2017; 5: 153-199
        • Ahmed Ali U.
        • Pahlplatz J.M.
        • Nealon W.H.
        • et al.
        Endoscopic or surgical intervention for painful obstructive chronic pancreatitis.
        Cochrane Database Syst Rev. 2015; : CD007884
        • Maartense S.
        • Ledeboer M.
        • Bemelman W.A.
        • et al.
        Effect of surgery for chronic pancreatitis on pancreatic function: pancreatico-jejunostomy and duodenum-preserving resection of the head of the pancreas.
        Surgery. 2004; 135: 125-130
        • Chen Y.I.
        • Levy M.J.
        • Moreels T.G.
        • et al.
        An international multicenter study comparing EUS-guided pancreatic duct drainage with enteroscopy-assisted endoscopic retrograde pancreatography after Whipple surgery.
        Gastrointest Endosc. 2017; 85: 170-177
        • Kurihara T.
        • Itoi T.
        • Sofuni A.
        • et al.
        Endoscopic ultrasonography-guided pancreatic duct drainage after failed endoscopic retrograde cholangiopancreatography in patients with malignant and benign pancreatic duct obstructions.
        Dig Endosc. 2013; 25: 109-116
        • Fujii L.L.
        • Topazian M.D.
        • Abu Dayyeh B.K.
        • et al.
        EUS-guided pancreatic duct intervention: outcomes of a single tertiary-care referral center experience.
        Gastrointest Endosc. 2013; 78: 854-864
        • François E.
        • Kahaleh M.
        • Giovannini M.
        • et al.
        EUS-guided pancreaticogastrostomy.
        Gastrointest Endosc. 2002; 56: 128-133
        • Kahaleh M.
        • Hernandez A.J.
        • Tokar J.
        • et al.
        EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts.
        Gastrointest Endosc. 2007; 65: 224-230
        • 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: 233-241
        • Ergun M.
        • Aouattah T.
        • Gillain C.
        • et al.
        Endoscopic ultrasound-guided transluminal drainage of pancreatic duct obstruction: long-term outcome.
        Endoscopy. 2011; 43: 518-525
        • Shah J.N.
        • Marson F.
        • Weilert F.
        • et al.
        Single-operator, single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla.
        Gastrointest Endosc. 2012; 75: 56-64
        • Vila J.J.
        • Pérez-Miranda M.
        • Vazquez-Sequeiros E.
        • et al.
        Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey.
        Gastrointest Endosc. 2012; 76: 1133-1141
        • Will U.
        • Reichel A.
        • Fueldner F.
        • et al.
        Endoscopic ultrasonography-guided drainage for patients with symptomatic obstruction and enlargement of the pancreatic duct.
        World J Gastroenterol. 2015; 21: 13140-13151
        • Tyberg A.
        • Sharaiha R.Z.
        • Kedia P.
        • et al.
        EUS-guided pancreatic drainage for pancreatic strictures after failed ERCP: a multicenter international collaborative study.
        Gastrointest Endosc. 2017; 85: 164-169
        • James T.W.
        • Baron T.H.
        Antegrade pancreatoscopy via EUS-guided pancreaticogastrostomy allows removal of obstructive pancreatic duct stones.
        Endosc Int Open. 2018; 6: E735-E738
        • Krafft M.
        • Nasr J.
        Anterograde endoscopic ultrasound-guided pancreatic duct drainage: a technical review.
        Dig Dis Sci. 2019; 64: 1770-1781
        • Cotton P.B.
        • Eisen G.M.
        • Aabakken L.
        • et al.
        A lexicon for endoscopic adverse events: report of an ASGE workshop.
        Gastrointest Endosc. 2010; 71: 446-454
        • Bekkali N.L.
        • Murray S.
        • Johnson G.J.
        • et al.
        Pancreatoscopy-directed electrohydraulic lithotripsy for pancreatic ductal stones in painful chronic pancreatitis using SpyGlass.
        Pancreas. 2017; 46: 528-530
        • Brauer B.C.
        • Chen Y.K.
        • Fukami N.
        • et al.
        Single-operator EUS-guided cholangiopancreatography for difficult pancreaticobiliary access (with video).
        Gastrointest Endosc. 2009; 70: 471-479
        • Oh D.
        • Park D.H.
        • Cho M.K.
        • et al.
        Feasibility and safety of a fully covered self-expandable metal stent with antimigration properties for EUS-guided pancreatic duct drainage: early and midterm outcomes (with video).
        Gastrointest Endosc. 2016; 83: e362
        • Dalal A.
        • Patil G.
        • Maydeo A.
        Six-year retrospective analysis of endoscopic ultrasonography-guided pancreatic ductal interventions at a tertiary referral center.
        Dig Endosc. 2020; 32: 409-416
        • Anderson M.A.
        • Akshintala V.
        • Albers K.M.
        • et al.
        Mechanism, assessment and management of pain in chronic pancreatitis: Recommendations of a multidisciplinary study group.
        Pancreatology. 2016; 16: 83-94
        • Hayat U.
        • Freeman M.L.
        • Trikudanathan G.
        • et al.
        Endoscopic ultrasound-guided pancreatic duct intervention and pancreaticogastrostomy using a novel cross-platform technique with small-caliber devices.
        Endosc Int Open. 2020; 08: E196-E202
        • Sauer B.G.
        • Gurka M.J.
        • Ellen K.
        • et al.
        Effect of pancreatic duct stent diameter on hospitalization in chronic pancreatitis: does size matter?.
        Pancreas. 2009; 38: 728-731
        • Binmoeller K.F.
        • Jue P.
        • Seifert H.
        • et al.
        Endoscopic pancreatic stent drainage in chronic pancreatitis and a dominant stricture: long-term results.
        Endoscopy. 1995; 27: 638-644

      Linked Article

      • EUS-directed pancreatic duct drainage: Mainstream miracle or proceed with caution?
        Gastrointestinal EndoscopyVol. 92Issue 5
        • Preview
          Abdominal pain is the foremost adverse event (AE) of chronic pancreatitis (CP). The mechanism of pain in CP is incompletely understood and likely multifactorial, including mechanical (intraductal pressure/obstruction), inflammatory, malabsorptive, and neurogenic/neuropathic changes in the pancreas and surrounding organs.1 In addition, patients with CP can have nonvisceral pain associated with high levels of psychologic stress. The intensity of pain and frequency of pain attacks compromise the quality of life in CP patients.
        • Full-Text
        • PDF