Post written by Soma Fukuda, MD, from the Department of Gastroenterology, Institute of Medicine, University of Tsukuba, Ibaraki, Japan.

We present a case of obstructive pancreatitis in a 70-year-old woman with pancreatic head cancer undergoing chemotherapy. Transpapillary pancreatic duct drainage failed because of complete ductal obstruction by the tumor.

EUS-guided pancreatic duct drainage was therefore attempted; however, the main pancreatic duct in the pancreatic tail was obscured by isoechoic debris on B-mode imaging, making safe puncture difficult. Contrast-enhanced harmonic EUS clearly delineated the main pancreatic duct as an avascular structure, whereas color Doppler helped identify peripancreatic vessels. Under real-time contrast-enhanced harmonic EUS guidance, the obscured duct was successfully punctured, and a plastic stent was placed from the main pancreatic duct to the stomach. The patient improved without adverse events.

EUS-guided pancreatic duct drainage is technically demanding because the main pancreatic duct is a small target, and precise visualization is essential. In some cases, debris, inflammation, or tumor-related changes can make the duct difficult to distinguish from the surrounding pancreatic parenchyma on conventional B-mode imaging. This video was important to showcase because it demonstrates how contrast-enhanced harmonic EUS can provide a practical “black-and-white” roadmap for ductal puncture, and color Doppler complements this by mapping vessels.

Other endoscopists can learn that contrast-enhanced harmonic EUS may be useful when the main pancreatic duct is obscured on B-mode imaging. The key lesson is to avoid relying on 1 imaging mode alone in difficult cases. A dual-imaging strategy, using color Doppler for vascular mapping and contrast-enhanced harmonic EUS for ductal visualization, may improve the safety and feasibility of challenging EUS-guided pancreatic duct drainage.

To our knowledge, this is the first report to highlight the practical use of contrast-enhanced harmonic EUS as a troubleshooting tool during EUS-guided pancreatic duct drainage when the main pancreatic duct is obscured.

Main pancreatic duct (MPD) puncture under contrast-enhanced harmonic EUS (CH-EUS) guidance. A, Although the MPD is poorly visualized on B-mode, CH-EUS clearly delineates the 3.2-mm-diameter duct as an avascular structure. B, Real-time visualization of the 22-gauge needle accurately entering the obscured MPD under CH-EUS guidance.

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