Therapeutic EUS for the Treatment of a Pancreaticopleural Fistual
Comments: Scott Cooper was given Material Support from Pentax Medical Company
Pancreatic duct injuries can often be successfully treated by endoscopic retrograde pancreaotography or ERP with pancreatic stent insertion. Unlike biliary strictures where perctuaneous transhepatic cholangography is an option after failed endoscopic retrograde cholaniography (ERC), such options are not available after failed ERP.
Therapeutic EUS techniques allow guidewire access into the pancreatic or bile duct in an anterograde fashion using EUS FNA. Once anterograde guidewire placement is achieved, pancreatic endotherapy is performed using standard ERCP techniques via a rendezvous procedure.
This video will demonstrate anterograde access of the pancreatic duct using EUS FNA along with the ERP rendezvous procedure, this video is the first to describe these techniques for the successful treatment of Pancreaticopleural fistula.
Case presentation:
A 72 year old gentleman with no significant past medical history presents with a two week history of progressive shortness of breath.
A chest X Ray shows a large left sided pleural effusion. A subsequent therapeutic thoarcentsis demonstrates a serosangenous pleural effusion with an amylase level of nearly 10,000 IU/Lm. The patient was found to have normal LFTs and CBC but his serum lipase was over 2400.
A CT scan was performed demonstrating the large left sided pleural effusion along with a possible fistula tract between the left lung base and the tail of the pancreas. Additionally, the pancreas duct was markedly dilated. However, no mass was seen in the head of the pancreas.
We first attempted to decompress the pancreatic duct via ERP. The ventral pancreatic duct was successfully canulated and the pancreaticogram, shown here, showed an abrupt cutoff of the ventral pancreatic duct in the head of the pancreas. These findings were suggestive of pancreatic divisum. Next we attempted to canulate the doral pancreatic ducts via the minor papilla using a tapered tip catheter but were unsuccessful.
We then proceeded with an EUS using a electronic linear array echoendoscope. The EUS showed a hypoechoic mass in the head of the pancreas 15 mm by 10 mm in size. A EUS FNA was then performed of the mass with cytology results showed only mild cytologic atypia suggestive of an inflammatory process rather than a malignancy.
As guidewire access could not be achieved via a retrograde approach, pancreatic duct guidewire placement via anterograde fashion was attempted.
A 19 gauge FNA needle is used to puncture the dilated pancreatic duct through the gastric antrum. Contrast injection was avoided at this stage to reduced the risk of pancreatic or pleural infection if the rendezvous procedure could not be successfully completed. These fluoroscopic images show the manipulation of a 0.035 inch guide wire through the FNA needle into the pancreatic duct proximal to the pancreatic mass then through the stricture and then through the ampula and into the douodenum.
The echoendoscope is then exchanged over the guidewire with care leaving the guide wire in placed. Next, a duodenoscope is introduced along side of the guidewire into the stomach. These findings confirm the patient has pseudodivisum due to obstruction of the ventral pancreatic duct.
Subsequently, a snare was used to gasp the guidewire in the duodenum, which was then pulled through the accessory channel of the duodenoscope.
Afterwards, a triple lumen catheter is advanced over the guidewire into the pancreatic duct stricture. Contrast injection shows a 15 mm stricture in the pancreatic duct with marked dilation of the upstream pancreatic duct.
Once the tip of the catheter is confirmed to be in the pancreatic duct, the guidewire is then pulled into the catheter. Further contrast injection clearly show a fistula between the tail of the pancreas and the left pleura.
Next, a pancreatic sphincterotomy was performed was performed using a traction sphinctertome. Afterwards, the pancreatic duct stricture is dilated with a 6 mm hydrostatic balloon to 10 atmospheres. Subsequently, a 7 F by 12 cm plastic pancreatic duct was stent was placed.
Clinical Follow-up
The patient returned in 6 weeks for repeat ERP with stent exchange. At this time he admits to drinking up to 5 alcoholic drinks a day.
A repeat CXR showed complete resolution of pleural effusion.
Repeat ERP demonstrated complete resolution of the Pancreaticopleural fistula. The pancreatic duct stricture was dilated further and two 7F pancreatic stents were placed.
Currently, for and a half months after initial presentation the patient remains asymptomatic.
Summary
1. This video demonstrated the successful treatment of a pancreatiocopleural fistula in a patient with pancreatic pseudodivisum caused by a inflammatory stricture in the pancreatic duct secondary to alcohol abuse
2. Additionally, this video demonstrated successful guidewire access into the pancreatic duct in an anteriograde fashion using EUS FNA after failed EPR
3. Lastly, this video demonstrates the ERP rendezvous technique allowing pancreatic endotherapy
Acknowledgements
ASGE Advanced Fellow Video Editing Course- 2008
Kevin McGrath, MD, Director of Endoscopy, UPMC PUH
Adam Silvka, MD, PhD, Associate Chief of the Division, UPMC, PUH
Jane Malik, RN
Pentax Medical Company for Material Support
| Contributed by: |
Scott T. Cooper, MD University of Pittsburgh |
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Citation: Cooper, ST (Jun 01 2009). Therapeutic EUS for the Treatment of a Pancreaticopleural Fistual. The DAVE Project. Retrieved Feb, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=862 Times viewed since Feb 2006: 1754 |
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