Post written by Erin Y. Chew, BS, Bibin T. Varghese, BS, and Robert J. Sealock, MD, from the Department of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA.
An 18-year-old woman presented to our hospital with diffuse abdominal pain and visible distention. She reported a history of acute pancreatitis 2 months earlier. Physical examination revealed diffuse abdominal tenderness without rebound and an abdominal fluid wave. CT of the abdomen and pelvis showed a large volume of ascites and marked dilation of the pancreatic duct to 16 mm, with a hypodense filling defect within the pancreatic duct near the head of the pancreas. On EUS, a hypoechoic heterogeneous intraductal lesion without posterior acoustic shadowing was visualized within the distal pancreatic duct with upstream dilatation to 10 mm.
On ERCP, attempts to pass a guidewire through the ampulla of Vater around the pancreatic duct lesion were unsuccessful. EUS also showed a 14.5- x 11.3-cm unilocular cyst without internal debris within the body of the pancreas, compressing the body/fundus of the stomach. Cyst aspiration revealed elevated amylase, low carcinoembryonic antigen, and no mucin, consistent with a pancreatic pseudocyst. Three days later, repeated EUS was performed in which the pancreatic duct was punctured proximal to the intraductal lesion with a 19-gauge FNA needle through the stomach wall. A 0.035-inch hydrophilic guidewire was then advanced through the needle into the pancreatic duct. The guidewire traversed beyond the intraductal lesion and exited into the duodenum through the minor papilla. Using the rendezvous guidewire, we inserted a cholangiopancreatoscope, and a pancreatic duct stone was visualized. Electrohydraulic lithotripsy was performed and the stone fragments were removed with the use of an extraction balloon. The epithelial lining did not show a fish-egg appearance or villous features to suggest an underlying intraductal neoplasm. An occlusion pancreatogram confirmed clearance of the stone. A 10F, 5-cm plastic pancreatic duct stent was inserted over the wire and deployed. An occlusion pancreatogram 4 weeks later showed no filling defect within the pancreatic duct. The duct of Wirsung was opacified and terminated at the level of the major ampulla.
In the past, obstructing pancreatic duct stones have been treated with a surgical lateral pancreaticojejunostomy and open-duct stone removal. However, endoscopic techniques to remove main pancreatic duct stones have been developed and include pancreatic sphincterotomy, stone retrieval (balloons, baskets, or rat-tooth forceps), stent placement, and mechanical lithotripsy. Endoscopic extraction of pancreatic duct stones is often more difficult than removing biliary calculi because pancreatic duct stones are usually harder and located behind strictures. We report a unique use of a rendezvous procedure to remove an obstructing pancreatic duct stone in the setting of pancreatic ascites and a symptomatic pancreatic pseudocyst.
An EUS-guided pancreatic duct rendezvous procedure can assist in removing larger stones when deep cannulation of the pancreatic duct through the major papilla is not feasible.
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