When ERCP Fails: EUS-Guided Access to Biliary and Pancreatic Ducts

Endoscopic ultrasound-guided pancreatic duct drainage: Progress and future outlook

As an innovative endoscopic intervention, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) demonstrates significant clinical value in resolving pancreatic ductal hypertension syndrome. By integrating real-time ultrasound guidance with catheter-based intervention techniques, this approach provides a safe and effective alternative for cases where conventional endoscopic retrograde cholangiopancreatography has failed. Current evidence indicates that EUS-PD achieves technical success rates ranging from 82% to 95% in alleviating symptomatic pancreatic duct hypertension caused by malignant obstructions and chronic pancreatitis-related strictures, with an overall complication rate (15%-20%) substantially lower than surgical interventions. Compared to conventional imaging modalities, EUS-PD offers superior anatomical visualization capabilities: Its high-frequency ultrasound probe enables precise identification of 3 mm-level pancreatic duct branches, while contrast-enhanced imaging significantly improves diagnostic accuracy in differentiating benign from malignant strictures (sensitivity 91% vs 73%, P < 0.05). Nevertheless, technical challenges persist, including difficult ductal puncture localization (particularly in pancreatic head lesions), complex guidewire axial control, and postoperative pancreatic fistula risks (7%-12%). This review systematically examines the clinical indications/contraindications, procedural protocols, device selection criteria, and management strategies for early/late complications associated with EUS-PD. Special emphasis is placed on establishing anatomical pathway selection standards for transgastric-pancreatic duct vs transduodenal-pancreatic duct approaches. Advancements in auxiliary technologies (e.g., three-dimensional elastography, AI-assisted navigation) and multidisciplinary team collaboration are pivotal to developing standardized protocols. We propose establishing international multicenter registry databases and conducting prospective randomized controlled trials to clarify EUS-PD's position within pancreatic disease management systems. Such initiatives will facilitate the clinical transformation of EUS-PD from an "alternative option" to a "preferred strategy", ultimately enhancing treatment precision and improving clinical outcomes in pancreatic disorders.

Technical outcomes between a drill dilator and ultra-tapered mechanical dilator during EUS-guided pancreaticogastrostomy: Comparative study

Background and study aims

Endoscopic ultrasound-guided pancreaticogastrostomy (EUS-PGS) is performed for patients who have failed ERCP. Tract dilation is one of the challenging procedural steps during EUS-PGS. Recently, a bougie dilator, the drill dilator, has become available. With this device, tract dilation can be easily performed without pushback of the echoendoscope, allowing stable scope positioning to be achieved during tract dilation. However, comparative studies between ultra-tapered mechanical and drill dilators have not been reported. The aim of this study was to compare the technical outcomes of these dilation devices.

Patients and methods

Symptomatic patients with main pancreatic duct (MPD) strictures from January 2021 to November 2023 were included in this retrospective study. The technical success rate of tract dilation was first evaluated. Overall technical success rate, procedure time, and adverse events were evaluated as secondary outcomes.

Results

The technical success rate of initial device insertion into the MPD was higher with the Tornus ES (100%, 12/12) compared with the ES dilator (60%, 9/15) ( P =0.013). Additional tract dilation rate to deploy the stent was needed in 86.7% (13/15) in the ES dilator group, and 8.3% (1/12) in the Tornus group ( P =0.001) and the overall technical success rate in the Tornus ES group was 100% (12/12). Mean procedure time was shorter in the Tornus ES group (13.38±3.80 min) compared with the ES dilator group (21.40±1.54 min) ( P =0.0013).

Conclusions

In conclusion, Tornus ES might be considered as the initial dilation device during EUS-PGS.

Techniques and Outcomes of Endoscopic Ultrasound Guided-Pancreatic Duct Drainage (EUS- PDD)

Endoscopic ultrasound guided-pancreatic duct drainage (EUS- PDD) is one of the most technically challenging procedures for the interventional endoscopist. The most common indications for EUS- PDD are patients with main pancreatic duct obstruction who have failed conventional endoscopic retrograde pancreatography (ERP) drainage or those with surgically altered anatomy. EUS- PDD can be performed via two approaches: the EUS-rendezvous (EUS- RV) or the EUS-transmural drainage (TMD) techniques. The purpose of this review is to provide an updated review of the techniques and equipment available for EUS- PDD and the outcomes of EUS- PDD reported in the literature. Recent developments and future directions surrounding the procedure will also be discussed.

Evaluating the role of endoscopic ultrasound in pancreatitis

INTRODUCTION

Endoscopic ultrasound (EUS) provides high-resolution images of both pancreatic parenchyma and duct and therefore is an integral component of evaluating and treating patients with pancreatitis and its complications. The development of enhanced EUS imaging techniques and newer EUS-specific accessories has expanded the diagnostic and therapeutic role of EUS in patients with acute and chronic pancreatitis (CP).

AREAS COVERED

This review discusses the current diagnostic and therapeutic role of EUS in acute pancreatitis (AP), CP, and autoimmune pancreatitis (AIP).

EXPERT OPINION

EUS plays a vital role in patients with AP by confirming the presence of common bile duct (CBD) stones in patients with acute biliary pancreatitis and intermediate probability of CBD stones. It plays an important role in the etiological evaluation of patients with idiopathic acute and recurrent pancreatitis. EUS is also an essential modality for diagnosing and managing pancreatico-biliary as well as gastroduodenal complications associated with CP. EUS-guided FNB using newer generation core biopsy needles has made possible accurate diagnosis of AIP by providing tissue samples with preserved architecture.