EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts

Background: EUS-guided pancreaticogastrostomy (EPG) has been reported as an alternative to surgery in cases of pancreatic stricture where ERCP is unsuccessful. Objective: We analyzed our 3-year experience with this innovative technique. Design: Patients with failed ERCP for pancreatic drainage were offered EPG over a 3-year period and were followed up prospectively in terms of clinical and radiologic response. Setting: Tertiary care center offering ERCP and interventional EUS. Patients: Thirteen patients were included in this study. Seven had surgical diversion. Six patients had unaltered enteral anatomy and stricture related to chronic pancreatitis (3), gallstone pancreatitis (2), and intraductal pancreatic mucinous neoplasm (1). Intervention: EUS-guided puncture and opacification of the pancreatic duct was performed, creating a transgastric fistula with placement of a guidewire into the main pancreatic duct and subsequent ductal decompression with a plastic endoprosthesis. Main Outcome Measurements: Mean main pancreatic duct size, pain score, and weight before and after intervention. Results: Ten patients had successful endoprosthesis placement across the pancreaticogastric fistula. One patient underwent brush cytologic study, which diagnosed pancreatic malignancy, and underwent surgical resection. After a mean follow-up of 14 months, the mean pancreatic duct size in treated patients decreased from 4.6 to 3.0 mm (P = .01); the pain score decreased from 7.3 to 3.6 (P = .01). Complications included one case of bleeding requiring hemoclip placement and 1 case of contained perforation. Limitations: Pilot study from a single center. Conclusions: EPG is a safe and feasible alternative to surgical intervention in this subgroup of patients where conventional ERCP is not possible.