Asian EUS Cup-07: Endoscopic ultrasound-guided pancreatic duct stenting with a new plastic stent for nondilated pancreatic duct in pancreatic fistula after pancreaticoduodenectomy

A 76-years-old man who underwent pylorus-preserving pancreaticoduodenectomy for lower cholangiocarcinoma developed peritonitis with intra-abdominal abscess from anastomotic leakage. We have done a reoperation for surgical drainage and jejunostomy for intestinal decompression. After operation, pancreatic leakage from anastomosis of pancreatico-jejunum was detected using contrast medium from jejunostomy. We tried percutaneous drainage for abscess several times but could not treat pancreatic leakage completely over 6 months hospitalization. The pancreatic duct stenting from the intestine by balloon endoscopy was impossible because of adhesion. We tried antegrade stenting using endoscopic ultrasound-guided pancreatic drainage (EUS-PD). In EUS findings, we could identify main pancreatic duct with a diameter of 1.3 mm. It is too thin to insert the needle for EUS-PD. Therefore, we punctured it with a 22-gauge needle and succeeded pancreatography. Then, we inserted 0.018 inch guidewire, and it reached into the duct of pancreatic head. After expanding the puncture site by ultra-tapered dilator and standard dilation catheter step-wisely, the guidewire was exchanged to 0.025 inch hard-type guidewire. We placed a new 7 Fr plastic stent smoothly across the pancreatic duct (Through Pass Type IT, Gadelius Medical, Tokyo, Japan); the distal part was in the intestine, and the proximal part (pigtail) was in the gastric lumen. Pancreatic leakage was improved and patient was discharged. EUS-PD with newly developed tube stent may be considered as an effective therapy in selected patients with a pancreatic leakage after pancreatectomy.