EUS rendezvous for pancreatic stent placement during endoscopic snare ampullectomy

Endoscopic ultrasound-guided pancreatic duct drainage

Endoscopic transpapillary or transanastomotic pancreatic duct drainage (PD) is the mainstay of drainage in symptomatic pancreatic duct obstruction or leakage. However, transpapillary or transanastomotic PD can be technically difficult due to the tight stricture or surgically altered anatomy (SAA), and endoscopic ultrasound (EUS)-guided PD (EUS-PD) is now increasingly used as an alternative technique. There are two approaches in EUS-PD: EUS-guided rendezvous (EUS-RV) and EUS-guided transmural drainage (EUS-TMD). In cases with normal anatomy, EUS-RV should be the first approach, whereas EUS-TMD can be selected in cases with SAA or duodenal obstruction. In our literature review, technical success and adverse event rates were 78.7% and 21.8%, respectively. The technical success rate of EUS-RV appeared lower than EUS-TMD due to the difficulty in guidewire passage. In future, development of dedicated devices and standardization of EUS-PD procedure are necessary.

Endoscopic Ultrasound-Guided Pancreatic Duct Intervention

Endoscopic ultrasound-guided pancreatic duct intervention (EUS-PDI) is an emerging endoscopic approach allowing access and intervention to the pancreatic duct (PD) for patients with failed endoscopic retrograde pancreatography (ERP) or patients with surgically altered anatomy. As opposed to biliary drainage for which percutaneous drainage is an alternative following failed endoscopic retrograde cholangiopancreatography (ERCP), the treatment options after failed ERP are very limited. Therefore, endoscopic ultrasound (EUS)-guided access to the PD and options for subsequent drainage may play an important role as an alternative to surgical intervention. However, this approach is technically demanding with a high risk of complications, and should only be performed by highly experienced endoscopists. In this review, we describe an overview of the current endoscopic approaches, basic technical tips, and outcomes using these procedures.

Endoscopic Ultrasound-Guided Pancreatobiliary Endoscopy in Surgically Altered Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) has become the mainstay of therapy for pancreatobiliary diseases. While ERCP is safe and highly effective in the general population, the procedure remains challenging or impossible in patients with surgically altered anatomy (SAA). Endoscopic ultrasound (EUS) allows transmural access to the bile or pancreatic duct (PD) prior to ductal drainage using ERCP-based techniques. Also known as endosonography-guided cholangiopancreatography (ESCP), the procedure provides multiple advantages over overtube-assisted enteroscopy ERCP or percutaneous or surgical approaches. However, the procedure should only be performed by endoscopists experienced in both EUS and ERCP and with the proper tools. In this review, various EUS-guided diagnostic and therapeutic drainage techniques in patients with SAA are examined. Detailed step-by-step procedural descriptions, technical tips, feasibility, and safety data are also discussed.

Endoscopic ultrasound-guided endotherapy

Over the last 2 decades, endoscopic ultrasound (EUS) has evolved from a noninvasive diagnostic tool to a combined diagnostic and therapeutic modality. The use of EUS complementary to endoscopic retrograde cholangiopancreatography (ERCP) has made possible biliary and pancreatic drainage in situations where conventional ERCP is unsuccessful or unlikely to be feasible. The degree of proximity to the pancreas achieved during the procedure has enabled therapeutic interventions such as drainage of peripancreatic fluid collections, pancreatic cyst ablation, and pancreatic cancer therapy. Real-time visualization of flow in adjacent blood vessels using Doppler ultrasound has allowed endovascular therapy for ablation of gastric varices and feeding vessels. Furthermore, the role of EUS is evolving in a multitude of applications such as bilioenteric and enteroenteric anastomosis in a minimally invasive manner, potentially reducing the need for surgery. This article reviews the role of EUS as an alternative to surgery in selective situations and provides an overview of future directions and evolving uses of EUS.

Recent advances in endoscopic papillectomy for ampulla of vater tumors: endoscopic ultrasonography, intraductal ultrasonography, and pancreatic stent placement

Since it was first described nearly three decades ago, endoscopic papillectomy (EP) has been utilized as a less invasive, alternative therapy for adenoma of the major duodenal papilla. In this article, we review the recent advances in EP, especially those pertaining to endoscopic ultrasonography (EUS), intraductal ultrasonography (IDUS), and pancreatic stent placement for the prevention of postpapillectomy pancreatitis. Because EUS and IDUS have similar diagnostic accuracies, either modality can be used for the preprocedural evaluation of ampullary tumors. Nevertheless, further technical refinements are required for a more precise evaluation. Given the paucity of data on the usefulness of EUS and/or IDUS during follow-up after EP, a well-designed study is warranted. Furthermore, pancreatic stent placement appears to have a protective effect against postpapillectomy pancreatitis; however, a prospective, randomized, controlled study with a larger number of patients is needed to assess this finding. Moreover, since pancreatic stent placement after EP is not always successful, various novel techniques have been developed to ensure reliable stent placement. Despite the recent advances in EP, further technical refinements and studies are needed to confirm their efficacy.

Pancreatic intubation facilitated by methylene blue injection decreases the risk for postpapillectomy acute pancreatitis

OBJECTIVES

Endoscopic snare papillectomy (ESP) is a viable alternative to surgical treatment of ampullary adenomas and T1N0 stage ampullary carcinomas. The main drawback of this technique is the high risk of acute pancreatitis post procedure.The aim of this study was to assess the efficacy, safety, and long-term results of this procedure, and to determine whether routine pancreatic intubation facilitated by intraductal methylene blue (MB) injection reduces the risk for pancreatitis.

PATIENTS AND METHODS

Between 2004 and 2011, 56 consecutive patients underwent ESP. Before resection, the pancreatic duct was cannulated, and MB was injected intraductally to facilitate stent placement after ampullectomy.

RESULTS

ESP was performed en bloc in 45 patients with histological findings of low-grade dysplasia (39%), high-grade dysplasia (25%), carcinoma (32.5%), and others (3.5%). The morbidity rate was 19.5%: acute pancreatitis (n=6), bleeding (n=4), perforation (n=1), and sepsis (n=1). Pancreatic intubation was performed in 89% of the patients. Postprocedure pancreatitis occurred significantly less in the patients with a pancreatic stent than in those without: 3/49 versus 3/6, P=0.013. ESP was considered as curative in 39 patients (75%). Of the 12 recurrences (25%), 10 were managed endoscopically, but with higher morbidity (acute pancreatitis=40%).

CONCLUSION

Endoscopic papillectomy is safe and effective in the hands of experts. Pancreatic-duct stent placement in fewer cannulation attempts could be facilitated by injection of MB before papillectomy, and this decreases the risk for postprocedure pancreatitis. Recurrences can be managed endoscopically, but with a higher risk for pancreatitis.

Technique of endoscopic ultrasonography-guided pancreatic duct intervention (with videos)

To date, several endoscopic ultrasonography (EUS)-guided interventions have been reported. Of these interventions, EUS-guided pancreatic duct (PD) intervention seems to be the most difficult and challenging procedure to accomplish. We provide suggestions for EUS-guided PD intervention, which includes PD stenting and the rendezvous technique following EUS-guided pancreatography. PD stenting is performed between the PD and the gastrointestinal tract (stomach, duodenum, or jejunum). The rendezvous technique is performed using a guidewire across the papilla or anastomotic site for retrograde stent insertion. EUS-guided PD intervention is still challenging because it is not established yet. Thus, although EUS-guided PD intervention seems to be promising, it should be performed in selected patients such as those of failed standard endoscopic retrograde cholangiopancreatography.

Endoscopic ultrasonography-guided drainage of the pancreatic duct

Over the last 2 decades there has been continuing development in endoscopic ultrasonography (EUS). EUS-guided pancreatic drainage is an evolving procedure that can be offered to patients who are high-risk surgical candidates and in whom the pancreatic duct cannot be accessed by endoscopic retrograde pancreatography. Although EUS-guided pancreatic drainage is a minimally invasive alternative option to surgery and interventional radiology, owing to its complexity and potential for fulminant complications it is recommended that these procedures be performed by highly skilled endoscopists. Additional data are needed to define risks and long-term outcomes more accurately via a dedicated prospective registry.

Endoscopic ultrasonography-guided pancreatic duct access: techniques and literature review of pancreatography, transmural drainage and rendezvous techniques

Endoscopic ultrasonography-guided (EUS)-guided pancreatic interventions have gained increasing attention. Here we review EUS-guided pancreatic duct (PD) access techniques and outcomes. EUS-guided PD intervention is divided into two types, antegrade and rendezvous techniques, following EUS-guided pancreatography. In the antegrade technique, pancreaticoenterostomy is carried out by stent placement between the PD and the stomach, duodenum, or jejunum. Transenteric antegrade PD stenting is conducted by stent placement, advancing anteriorly into the PD through the pancreatic tract. The rendezvous technique is carried out by using a guidewire through the papilla or anastomotic site for retrograde stent insertion. In terms of EUS-guided PD stenting, 11 case reports totaling 75 patients (35 normal anatomy, 40 altered anatomy) have been published. The technical success rate was greater than 70%. Early adverse events, including severe hematoma and severe pancreatitis,occurred in seven (63.6%) of 11 reports. Regarding the rendezvous technique, 12 case reports totaling 52 patients (22 normal anatomy, 30 altered anatomy) have been published. The technical success rate ranged from 25% to 100%. It was 48% in one report that involved more than 20 cases. Once stents were placed, all patients became free of symptoms. Early mild adverse events occurred in four (36.4%) of 11 reports. In conclusion, although it can be risky because of possible serious or even fatal adverse events, including pancreatic juice leakage, perforation and severe acute pancreatitis, EUS-PD access seems to be promising for treating symptomatic pancreatic diseases caused by PD stricture and pancreaticoenterostomy stricture.

Systematic pancreatic stenting after endoscopic snare papillectomy may reduce the risk of postinterventional pancreatitis

BACKGROUND

Pancreatitis is the most feared complication of endoscopic papillectomy (EP). Prevention by pancreatic duct stenting following EP has been advocated but not proven by a randomized trial. The purpose of the present retrospective review is to compare a period of systematic stenting with the period before in which stents were placed selectively.

METHODS

A total of 107 patients undergoing EP from February 1999 to December 2009 were retrospectively reviewed. After an initial period with selective stenting (dilated duct, previous pancreatitis) between 1999 and 2002 (n = 24, group 1), stents were placed routinely after EP unless pancreas divisum was diagnosed (2002-2009; n = 83, group 2) to reduce postpapillectomy acute pancreatitis (PAP). PAP rates defined by Consensus Criteria were compared in the two periods.

RESULTS

Five patients in group 1 were selected to receive a pancreatic stent (21%); in group 2 stenting was successful in 75 of 78 patients (success rate 96%) without pancreas divisum (n = 5). Overall, PAP occurred in 11% of patients. PAP rate was significantly reduced after introduction of systematic pancreatic stenting (5 vs 25%; p = 0.01) and occurred less often in stented than in nonstented patients: (5% (4/80) vs 27% (6/22), p = 0.0019). PAP also occurred in one of five patients with pancreas divisum. Selective stenting of patients also was an independent risk factor for PAP (OR 13, p = 0.001) in a multivariate analysis.

CONCLUSIONS

Attempts at systematic stenting after EP pancreatic stenting appears to prevent PAP. Results should be corroborated by a randomized trial.

Endoscopic diagnosis and management of ampullary lesions

Most (>95%) ampullary lesions are adenomas or adenocarcinomas. Side viewing endoscopy, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are complementary procedures that have an important role in the diagnosis, staging, and treatment of ampullary lesions. Here the authors review their epidemiology and discuss the evidence for endoscopic modalities, with an emphasis on techniques for endoscopic resection. Although endoscopic papillectomy represents one of the highest-risk endoscopic interventions, it has largely replaced surgical modalities for the treatment of adenomatous lesions. Appropriate patient selection and use of preventive maneuvers will minimize the likelihood of persistent or recurrent lesions and postprocedure complications.

Therapeutic endoscopic ultrasound for biliary and pancreatic disorders

The role of endoscopic ultrasound (EUS) has greatly expanded since the first clinical examination performed nearly 30 years ago. The introduction of linear instruments allowed tissue sampling (Kulesza and Eltoum Clin Gastroenterol Hepatol 5:1248-1254, 2007; Levy and Wiersema Gastrointest Endosc 62:417-426, 2005) and therapeutic interventions applications, including celiac plexus and ganglia blockade and neurolysis (Wiersema and Wiersema Gastrointest Endosc 44:656-662, 1996; Levy and Wiersema Gastroenterol Clin North Am, 35:153-165, 2006; Levy et al. Am J Gastroenterol 103:98-103, 2008), pancreatic fluid drainage (Lopes et al. Arq Gastroenterol 45:17-21, 2008; Norton et al. Mayo Clin Proc 76:794-798, 2001; Kruger et al. Gastrointest Endosc 63:409-416, 2006; Seifert et al.: Endoscopy 32:255-259, 2000), cholecystenterostomy (Kwan et al. Gastrointest Endosc 66:582-586, 2007), and delivery of cytotoxic agents (eg, chemotherapy, radioactive seeds, and gene therapy) (Chang et al.: Cancer 88:1325-1335, 2000; Chang Endoscopy 38(Suppl 1):S88-S93, 2006). The continued need to develop less invasive alternatives to surgical and interventional radiologic therapies drove the development of EUS-guided methods for biliary and pancreatic intervention. This article reviews existing data and focuses on established and emerging EUS techniques for accessing and draining the bile and pancreatic ducts.

Pancreatic ductal drainage by endoscopic ultrasound-assisted rendezvous technique for pain caused by ductal stricture with chronic pancreatitis

With the advances in echoendoscopes, the frontier of therapeutic endoscopic ultrasonography (EUS) is expanding. A 50-year-old male presented to us with unrelenting pain following an episode of alcoholic pancreatitis. Imaging studies revealed evidence of pancreatic ductal hypertension with a pseudocyst in the head of the pancreas. Following unsuccessful attempts at drainage of the pancreatic duct (PD) via the minor or major papilla at endoscopic retrograde cholangiopancreatography, he underwent endoscopic ductal drainage with the EUS-assisted rendezvous technique. The PD was punctured under the guidance of EUS. A guidewire was then introduced into the PD and was guided into the duodenal lumen through the minor papilla. The tip of the guidewire was grasped with forceps coming out of a duodenoscope introduced instead of the echoendoscope. A pancreatic stent was inserted over the guidewire across the minor papilla. After the endoscopic pancreatic stenting, the patient achieved symptomatic relief.

Therapeutic EUS-assisted endoscopic retrograde pancreatography after failed pancreatic duct cannulation at ERCP

BACKGROUND

Cannulation of the pancreatic duct (PD) during endoscopic retrograde pancreatography (ERP) can fail even in experienced hands. A technique for therapeutic EUS-assisted rendezvous ERP has been described in a few case reports.

OBJECTIVE

To investigate the efficacy and safety of therapeutic EUS-assisted ERP.

DESIGN

Retrospective study.

SETTING

Tertiary-care medical center.

PATIENTS

This study involved 21 patients after failed ERP.

INTERVENTION

EUS-guided transgastric pancreatography by using a mixture of contrast media and methylene blue was attempted. If that was successful, ERP was attempted by using methylene blue flow as an indicator of the PD orifice or by a rendezvous technique using a wire passed into the PD and the small bowel through the EUS needle.

MAIN OUTCOME MEASUREMENTS

Technical success rate and complications.

RESULTS

The PD was of a normal diameter in 7 patients and was dilated in 14 patients. EUS-guided pancreatography was successfully done in all patients with a dilated PD but only in 4 of 7 patients (57%) with normal-diameter PDs. In 6 patients, ERP was successfully performed by using methylene blue flow as an indicator of the PD orifice. The rendezvous technique was successful in 4 of 12 cases (33%), and reasons for failure were either a tight stricture (n = 5) or a suboptimal angle of EUS needle insertion (n = 3). Overall, EUS-assisted ERP was successful in 10 of 21 patients (48%). Complications included peripancreatic abscess in 1 patient and mild pancreatitis in 1 patient.

LIMITATIONS

Retrospective study, small sample size.

CONCLUSION

EUS-assisted ERP is a complex procedure that can provide access to the PD in selected cases after failed standard ERP.

Endosonography-guided pancreatic duct drainage for chronic pancreatitis: a case report and review

A 50-year-old man was admitted to our department, complaining of epigastric pain and high fever. CT revealed a pseudocyst at the pancreatic head with upstream dilatation of the pancreatic duct (PD) and fluid collection surrounding the pancreas. Endosonography-guided PD drainage (ESPD) was performed because of unsuccessful ERCP. With a curved linear array echoendoscope, a 7.2 F catheter was placed in the PD. Laboratory data showed improvement in a few days and revealed disappearance of the fluid collection. Ten days after ESPD, a 7 F stent was placed in the PD via the puncture tract across the papilla of Vater followed by transpapillary replacement with a 10 F stent. CT showed a reduction in diameter of the PD and disappearance of the pseudocyst. ESPD is a feasible and useful procedure in selected patients with chronic pancreatitis showing stenosis of the main PD when transpapillary approach is impossible.

Endosonography-guided pancreatic duct drainage for chronic pancreatitis

Although endoscopic transpapillary treatment of chronic pancreatitis (CP) is gaining acceptance, it is not always possible, especially in patients with inflammatory stenosis of the duodenum due to CP or with a history of a Whipple's procedure. Linear array echoendoscopes (ES) provide high-quality images of the pancreas along with adjacent organs and allow therapeutic applications. echoendoscope-related procedures, such as ES-guided pancreatic duct drainage (ESPD) are feasible and useful in selected patients with CP suffering from PD stricture in whom conventional endoscopic retrograde cholangiopancreatography (ERCP) is impossible.

Endoscopic papillectomy

PURPOSE OF REVIEW

Although few controlled trials exist in the field, endoscopic papillectomy has evolved over the recent years with new data on preoperative staging and improved methods for its safe and successful completion. In 2006, a consensus guideline was published by the American Society of Gastrointestinal Endoscopy evaluating the role of endoscopy in managing ampullary adenomas.

RECENT FINDINGS

The recent literature of endoscopic papillectomy has focused on the preoperative management of ampullary tumors, with a paper evaluating the role of endoscopic ultrasound. Also, a randomized controlled trial has shown that the use of pancreatic duct stents is associated with less incidence of postendoscopic papillectomy pancreatitis, although the study was probably underpowered. Several methods can be used to help locate the pancreatic duct postendoscopic papillectomy (endoscopic ultrasound-guided rendezvous and methylene blue injection). The recurrence and complication rate in more recent papers continue to be acceptable, at about 30 and 20%, respectively.

SUMMARY

Endoscopic papillectomy is a reasonable alternative to transduodenal surgical excision, but more controlled studies with long-term data are needed to evaluate preoperative staging accuracy and recurrence rates.