EUS for Pancreaticobiliary Duct Access and Drainage
EUS-guided pancreaticobiliary access was reported in the early 1990s, and since then we have seen tremendous progress in technique to access the pancreaticobiliary system, passing wire through stricture to guide retrograde intervention (rendezvous), and to establish direct drainage routes. This technique has been utilized in tertiary care centers for pancreaticobiliary disease, where technical success rate of ERCP is high but there is sometimes a need for other methods of therapy due to certain conditions or anatomic constraints. EUS-guided access and drainage are highly successful in trained hands, however, higher complication rates remain an issue even at high-volume centers. A variety of techniques are available, and there are certain steps endoscopists should know to increase success and to reduce complications. This chapter is aimed to guide readers when and how to use this useful but challenging technique of pancreaticobiliary access and drainage.
KeywordsEUS-guided pancreaticobiliary access EUS-guided drainage Rendezvous-retrograde intervention Antegrade intervention ERCP EUS-guided pancreatography Choledochoduodenostomy Hepaticogastrostomy Pancreaticogastrostomy Complications
Endoscopic retrograde cholangiopancreatography
Endoscopic retrograde pancreatography
Percutaneous transhepatic cholangiogram
Self-expandable metal stent
Case 1: From the stomach, the left lobe of the liver was visualized with a linear echoendoscope. The left lateral segment bile duct was accessed with a 19G needle and contrast was injected. Excessive contrast injection was avoided to minimize leakage. A 0.025 in angled wire was passed through the needle and carefully manipulated to pass through the stricture. The wire was torqued as needed to direct towards the predicted confluence and then towards the extrahepatic duct. Withdrawal of the wire was done very carefully to avoid stripping the wire covering. Smooth advancement of the wire is seen towards the ampulla, and the wire was further advanced to loop inside the duodenum. The wire was successfully passed into the duodenum via the major papilla. The wire was seen with the exchanged duodenoscope. The wire tip was captured into the snare and carefully pulled into the channel to complete retrograde stent placement (MP4 93854 kb).
Case 4: 47 y.o. male with a history of FAP underwent pancreas-sparing duodenectomy and creation of a neo-ampulla for a fully circumferential large duodenal adenoma. This was complicated with persistent pancreas ascites. ERCP was performed and the biliary orifice was easily identified; however, pancreas duct access failed, suggesting stenosis at the orifice. EUS-guided intervention was planned after thorough discussion (MP4 83553 kb).
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