Advanced technique for the treatment of chronic calculous pancreatitis using endoscopic ultrasound-guided pancreatic duct drainage.

A 64-year-old man who underwent distal gastrectomy with Billroth II reconstruction for duodenal ulcer perforation was hospitalized for painful chronic pancreatitis. The recurrent pain was caused by calculous obstruction of the pancreatic duct, resulting in upstream ductal hypertension. Computed tomography showed stones and a dilated main pancreatic duct (MPD) (▶Fig. 1). We performed endoscopic retrograde pancreatography (ERP); however, we could not insert the guidewire deeply (▶Fig. 2). Therefore, we tried endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD). However, the guidewire could not be advanced across the papilla and tended to coil within the MPD. Hence, a fully covered metal stent was placed from the MPD to the stomach (▶Fig. 3). After the fistula had matured, we again attempted guidewire advancement, which was difficult. Therefore, an intraductal pancreatoscope (IDP; SpyGlass DS system; Boston Scientific Corp., Natick, Massachusetts, USA) was inserted through the pancreatogastrostomy to facilitate direct visualization. The IDP image indicated complete obstruction of the MPD by the stones. Therefore, electrohydraulic lithotripsy (EHL; Lithotron EL 27 Compact; Walz Elektronik, Rohrdorf, Germany) was performed. The stones could be fragmented, allowing the guidewire to be negotiated through the minor papilla (▶Fig. 4; ▶Video 1). We exchanged the scope for a colonoscope, dilated the minor papilla using a balloon up to 4mm, and finally placed a 7 Fr single-pigtail stent from the minor papilla to the fistula using a rendezvous technique (▶Fig. 5). There were no adverse events. Although ERP is the conventional method for treating pancreatic ductal obstruction, it is sometimes challenging in patients with tight stenosis, complete ductal obstruction, or surgically altered anatomy [1]. Recently, EUS-PD has been E-Videos