Successful transgastric pancreaticography and endoscopic ultrasound-guided drainage of a disconnected pancreatic tail syndrome.

OBJECTIVES: We aim to demonstrate that endoscopic ultrasound (EUS)-guided transgastric pancreaticography/drainage of the pancreatic duct is feasible and successful in healing a persisting pancreaticocutaneous fistula.
METHODS: By means of a case report, we describe the following alternative therapeutic procedure. A 76-year-old male had: (1) 10 surgical interventions because of necrotizing acute pancreatitis with a persisting pancreaticocutaneous fistula (volume 200-300 ml/day); (2) an unsuccessful attempt of transpapillary drainage (disrupted duct after necrosectomy). He then underwent a EUS-guided transluminal pancreaticography/drainage of the pancreatic duct. A transgastric puncture was performed followed by, insertion of a guide wire into the dilated tail segment, and expansion of the gastropancreaticostomy using a 10-Fr retriever. A 10-Fr Amsterdam prosthesis was then placed through the guide wire.
RESULTS: The procedure was both a technical and clinical success as indicated by fistula occlusion and sufficient internal drainage of the pancreatic juice via the gastropancreaticostomy. No severe complications such as bleeding, perforation stent occlusion or migration were observed during the 15-month follow-up.
CONCLUSIONS: Transgastric pancreaticography and EUS-guided drainage of the enlarged pancreatic duct are elegant and feasible alternative options for the treatment of specific pancreatic lesions such as persisting pancreaticocutaneous fistula (complication after necrotizing pancreatitis), after pancreatic resective surgery, chronic pancreatitis and anomaly of the congenital pancreatic or postoperative gastrointestinal anatomy. Moreover, the procedure may represent a valid tool to avoid surgery and more invasive interventions.