A 65-year-old woman was arranged for an open surgical cystogastrostomy due to pseudocyst after a pancreatitis attack. Six months later, she began experiencing recurrent pancreatitis.
The magnetic resonance cholangiopancreatography showed an upstream duct dilation and extremely benign stenosis at the pancreatic neck. A pseucyst was found near the pancreas. The gastroscope confirmed that her surgical fistula was closed [Figure 1]. Thus, pancreatic drainage (PD) ought to be the key treatment.
Figure 1.
(a), Magnetic resonance cholangiopancreatography showed the extremely benign stenosis at the neck region (arrow) and a tiny residual cyst near the pancreatic neck (arrowhead). (b), Endoscopic image confirmed the occluded surgical fistula in the gastric.
Endoscopic retrograde pancreatography transpapillary drainage was our initial attempt. The guidewire (Innovex) could be advanced retrogradely across the stenosis until the tail portion. However, injected contrast medium failed to show the upstream filling [Figure 2]. All attempts to dilate the stenosis were also failed. Then we converted to EUS-PD drainage. The upstream duct’s dilation was demonstrated using EUS [Olympus; Figure 3]. The posterior stomach wall was successfully penetrated by a 19G needle-knife (Wilson Cook) coaxial with a guidewire (VisiGlide) after ruling out vessels along the targeting puncture track. When contrast agent was administered, fluoroscopy showed the pancreatic duct and gastric cavity photograms [Figure 3]. A 6F cystotome (Boston Scientific) following guidewire was used for tract dilation. Then, a 7F 250-mm double-pigtail plastic stent was successfully placed with a bidirectional ring drainage through the fistula into the stomach [Figure 3].
Figure 2.
The endoscopic retrograde pancreatography guidewire (arrowhead) could be advanced retrogradely until the pancreatic tail, but the contrast media (arrow) could not show the upstream duct’s filling.
Figure 3.
(a), Echoendoscope demonstrated the dilation of the upstream main pancreatic duct (arrow). (b), Fluoroscopy showed the photograms of pancreatic duct (arrow) and gastric cavity (arrowhead). (c), A double-pigtail plastic stent was deployed into pancreatic duct and transmitted through the fistula into the stomach.
However, the interventions were repeated monthly because of stent migrations. After several failing attempts at stent secure schemes, using clips with nylon drawstrings at both the proximal and distal ends, we finally fasten a 7F 200-mm stent (remolded from our suspended overlength biliary stent[1]) at the gastric wall [Figure 4]. The patient had remained asymptomatic until now.
Figure 4.
The hanging overlength biliary stent was fastened with nylon drawstrings and clips at both the proximal (a) and distal ends (b) at the stomach wall.
Pancreatic duct obstruction can develop as a complication of many diseases.[2] Although EUS-guided transmural drainage, being the primary therapy choice for patients, failed endoscopic retrograde cholangiopancreatography, open surgical surgery still has a place.[3] In this work, we described the first case in which a cystogastrostomical fistula was successfully reopened using EUS-PD and a bidirectional ring drainage stent.
Author Contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Zhipeng Lin and Yingchun Wang. The first draft of the manuscript was written by Zhipeng Lin and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Financial Support and Sponsorship
Nil.
Declaration of Patient Consent
We have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Footnotes
Z.L and Y.W. contributed equally to this work.
Published online: 1 December 2023
Contributor Information
Zhipeng Lin, Email: linzhipeng1217@outlook.com.
Yingchun Wang, Email: wangyingchun2023@sina.com.
Wenzheng Liu, Email: huangyonghui2022@sina.com.
Xiue Yan, Email: huangyonghui2022@sina.com.
Hong Chang, Email: huangyonghui2022@sina.com.
Yonghui Huang, Email: huangyonghui2022@sina.com.
Conflicts of Interest
There are no conflicts of interest.
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