Endoscopic ultrasound-guided choledochoduodenostomy and duodenal stenting in patients with unresectable periampullary cancer: one-step procedure by using linear echoendoscope.

OBJECTIVE: Describe a case series of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CD) associated with duodenal self-expandable metal stents (SEMS) placement using solely the linear echoendoscope in seven patients with obstructive jaundice and duodenal obstruction due to unresectable periampullary cancer. MATERIAL AND METHODS: EUS-CD in the first portion of the duodenum, associated with duodenal SEMS placement was performed in seven patients with unresectable periampullary cancer with obstructive jaundice and invasive duodenal obstruction. Laboratory tests and clinical follow-up were performed until patient's death. The procedure was performed by an experienced endoscopist under conscious sedation. The puncture position was chosen based on EUS evaluation, at the common bile duct (CBD) above the tumor, through the distal part of the duodenal bulb. After that, the needle was withdrawn and a wire-guided needle knife was used to enlarge the site puncture in the duodenal wall. Then, a partially covered SEMS was passed over the guide, through the choledochoduodenal fistula. Duodenal SEMS placement was performed during the same endoscopic procedure. RESULTS: The procedure was performed in seven patients, ranging between 34 and 86 years. Technical success of EUS-CD, by the stent placement, occurred in 100% of the cases. There were no early complications. Duodenal SEMS placement was effective in 100% of the cases that remained alive after a follow-up of 7 and 30 days. CONCLUSION: The results suggest therapeutic EUS one-step procedure drainage as an alternative for these patients, with good clinical success, feasible technique and safety.

EUS-Guided access to dorsal pancreatic duct in a patient with pancreas divisum

Se reporta un caso de acceso del conducto pancreatico dorsal por medio de ayuda de ultrasonografía endoscópica en un paciente con cuadro de Páncreas divisum que producía sintomas dolorosos; y que no fué posible su abordaje por PCRE.

Case report of pancreas divisum dorsal pancreatic duct access with endoscopic ultrasonography help to relief pain in a patient with not possible access by PCRE.

A novel endoscopic treatment of pancreas divisum (un tratamiento endoscópico nuevo para el páncreas divisum)

El páncreas divisum es la malformación congénita más común del páncreas que resulta de la no fusión ó fusión incompleta de las porciones ventral y dorsal del páncreas embrionario. Se encuentra en 7% de los estudios de autopsias (rango 1-14%), siendo generalmente asintomática. Un 5% de estos pacientes presentan síntomas, que son básicamente dolor abdominal y casos de pancreatitis recurrente. Se reporta el caso de una paciente mujer de 52 años, con 2 episodios de pancreatitis postcolecistectomía con imagen por colangioresonancia de páncreas divisum con comunicación entre el páncreas dorsal y ventral. Se procedió a dilatar el conducto mayor; y luego se hizo una papilotomia del conducto menor y se pasó un balón hidroneumático hasta más allá de su diámetro mayor. El procedimiento ha tenido éxito en 9 meses de seguimiento.

Pancreas divisum is the most common congenital malformation of the pancreas that results from the non-fusion or incomplete fusion of the ventral and dorsal portionts of the embryonic pancreas. It is found in 7% of autopsy studies (range 1-14%) and is generally asymptomatic. 5% of the patients have symptoms, wich are basically cases of abdominal pain and recurrent pancreatitis. We report the case of a woman of 51y, postcholecystectomy with 2 episodes of pancreatitis with imaging from magnetic resonance of pancreatic divisum with communication between the dorsal and ventral pancreas. We proceeded bye endoscopy (ERCP) to dilate the major duct, and them made a minor duct papillotomy and made a hydropneumatic ball dilatation with the catheter balloon up the waist portion. The procedure was successful with 9 months of follow up.