Endoscopic ultrasound-guided pancreatic duct intervention and pancreaticogastrostomy using a novel cross-platform technique with small-caliber devices.

Endoscopic ultrasound (EUS)-guided pancreaticogastrostomy (PG) has been used as an alternative to surgery to drain pancreatic ducts for treatment of disconnected pancreatic duct syndrome (DPDS). Previous techniques involved using needle-knife cautery, bougie dilation or a stent extraction screw to allow stent passage through the gastric wall and pancreatic parenchyma, with potential for severe complications including duct leak, especially if drainage fails. A novel technique employing EUS guided puncture of the main pancreatic duct (MPD) with a 19- or a 22-gauge needle, passage of an 0.018-guidewire, dilation of the tract with a small-diameter (4 F) angioplasty balloon and placement of 3F plastic stents with the pigtail curled inside the duct as an anchor. This is a retrospective case series at a single tertiary center. EUS-guided PG was considered when conventional endoscopic pancreatic duct drainage failed. Main outcomes included technical and clinic success and complications. Eight patients underwent PG. Indications were DPDS (n = 4), stenotic pancreaticoenteral anastomosis after Whipple procedure (n = 3) and chronic pancreatitis with dilated MPD (n = 1). Median MPD diameter was 6.75 mm [IQR 2.8 - 7.6]. Technical success was achieved in seven of eight cases (88 %); angioplasty balloon passed into the pancreatic duct in all accessed ducts. There was one asymptomatic duct leak, and no major or delayed complications, with clinical improvement (complete or partial) in five of eight (71 %).  EUS-guided PG using a small-caliber guidewire, 4F angioplasty balloon, and reverse 3F single pigtail stents offers a safe and atraumatic alternative without use of cautery.