What is the recommended approach for endoscopic intervention in patients with disrupted pancreatic duct syndrome (DPDS) when traditional methods like Endoscopic Retrograde Cholangiopancreatography (ERCP) are not feasible or have failed?

Endoscopic Ultrasound-Guided Pancreatic Duct Drainage (EUS-PD) in Disconnected Pancreatic Duct Syndrome (DPDS)

EUS-guided pancreatic duct drainage is strongly recommended as the procedure of choice for patients with disconnected pancreatic duct syndrome when conventional ERCP has failed or is not feasible due to altered anatomy. 1

Indications for EUS-PD in DPDS

• EUS-PD is indicated in patients with pancreatic duct obstruction after failed ERCP attempts (Level of agreement: 8.0, Evidence level: Moderate) 1
• EUS-PD is strongly recommended in patients with pancreatic duct obstruction and surgically altered anatomy or duodenal stenosis where ERCP is not possible (Level of agreement: 9.0, Evidence level: Moderate) 1
• Main indications include MPD strictures due to chronic pancreatitis, strictures of pancreaticojejunal or pancreaticogastric anastomosis after Whipple resection, and management of external pancreatic fistulae in DPDS 2, 3

Technical Approaches for EUS-PD

EUS-PD can be achieved through three main techniques:

• Rendezvous technique: Used when the papilla is accessible but conventional cannulation fails
• Pancreaticogastrostomy/pancreaticoduodenostomy: Direct transmural drainage
• Antegrade drainage: Placement of a stent across the obstruction

(Level of agreement: 8.0, Evidence level: Moderate) 1

Procedural Considerations

Pre-procedure Planning

• Appropriate imaging including MRCP or contrast-enhanced CT is essential before attempting EUS-PD to understand pancreatic duct anatomy and plan the approach (Level of agreement: 9.0) 1
• Antibiotic prophylaxis is recommended before the EUS-PD procedure (Level of agreement: 8.0) 1

Technical Aspects

• The transgastric approach should be used as the initial approach for EUS-PD (Level of agreement: 8.0, Evidence level: Low) 1
• A 19-gauge needle is recommended for pancreatic duct puncture 1
• Following puncture, a 0.035 inch or 0.025 inch guidewire with floppy tip should be used to negotiate the pancreatic duct and papilla (Level of agreement: 9.0) 1
• Catheters, dilators, cystotomes, or balloons are recommended for track dilation (Level of agreement: 9.0) 1
• Plastic stents without intervening side holes between the ends of the stent are recommended for EUS-PD (Level of agreement: 8.0, Evidence level: Low) 1

Outcomes and Efficacy

• Technical success rates range from 63% to 100%, with an overall rate of approximately 85% 4
• Clinical success rates range from 76% to 100%, with an overall rate of approximately 88% 4
• EUS-PD has shown significantly higher technical and clinical success rates compared to enteroscopy-assisted ERP (92.5% vs 20% and 87.5% vs 23.5%, respectively) 1
• For external pancreatic fistulae in DPDS, endoscopic techniques including EUS-guided transmural drainage have shown healing rates of up to 94% 5

Adverse Events and Complications

• Short-term adverse events occur in approximately 25% of cases 4
• Common complications include:
  • Abdominal pain
  • Acute pancreatitis
  • Bleeding
  • Pancreatic juice leakage leading to perigastric or peripancreatic fluid collections 4
• Complication rates of EUS-PD are higher than conventional ERCP, necessitating multidisciplinary support 1

Institutional and Operator Requirements

• EUS-PD should only be performed at expert centers with facilities and expertise in interventional EUS and advanced ERCP (Level of agreement: 9.0) 2
• Multidisciplinary support including interventional radiologists, surgeons, and anesthesiologists is recommended to prevent and manage complications (Level of agreement: 9.0, Evidence level: Low) 1
• The procedure should be performed by experienced endoscopists skilled in EUS-FNA, wire manipulation techniques, and stent placement (Level of agreement: 9.0) 4

Recent Developments and Special Considerations

• For patients with external pancreatic fistulae in DPDS, various EUS-guided techniques have been developed:
  • Transmural placement of pigtail stents through gastric openings
  • EUS-guided transmural puncture of fluid collections
  • Direct EUS-guided puncture of fistula tract
  • EUS-guided pancreaticogastrostomy 5
• Newer short-type double or single balloon enteroscopes have improved success rates in reaching the blind end of the roux limb (92.6-97%), potentially offering an alternative to EUS-PD in select cases 1

Pitfalls and Caveats

• EUS-PD remains a technically challenging procedure with a high risk of adverse events 4
• The procedure should not be attempted without appropriate imaging and pre-procedure planning 1
• Stent placement alone without papillotomy or dilation is unlikely to produce durable results 1
• Asymptomatic spontaneous external migration of stents may occur in approximately 29% of patients 5
• Training should include experience with pig or ex vivo models before attempting on patients 1