Advanced endoscopic interventions on the pancreas and pancreatic ductal system: a primer for radiologists

Rendezvous Technique for Advanced Pancreatic Duct Interventions

Interventional radiology can be used to perform complex pancreatic duct (PD) interventions in cases in which PD abnormalities limit the feasibility of an endoscopic approach. A multidisciplinary approach with gastroenterology using the rendezvous technique can improve procedural success. The establishment of through-and-through access to the PD via a combined percutaneous and endoscopic approach can be used when endoscopy alone fails. In this study, 3 cases are presented in which the rendezvous technique was successfully employed to access the PD for subsequent interventions.

Mind the Gap-Disconnected Duct Syndrome: A Review of Current Diagnostic and Management Strategies

ABSTRACT

Disconnected duct syndrome (DDS) is an adverse sequela of acute necrotizing pancreatitis in which there is disruption of the pancreatic duct leading to a failure to deliver pancreatic secretions into the duodenum. Its presentation may range from a persistent external pancreatic fistula to a treatment-resistant pancreatic pseudocyst. The diagnosis is often delayed in the acute setting if there is concurrent necrosis as management is often directed to the associated peripancreatic fluid collection. A combination of imaging modalities may be required to evaluate ductal anatomy. No definitive consensus has been achieved regarding the optimal treatment strategy for DDS, and there is a lack of published level I evidence on the topic. Treatment should be tailored to each individual patient, depending on the anatomy of ductal disruption, the presence of sepsis, the degree of physiological derangement, and the patients' performance status. Patients with DDS represent a specific cohort of patients with complex pancreatic disease that requires the input from a diverse multidisciplinary team to ensure that a good clinical outcome can be achieved.

Lumen-apposing metals stents in advanced endoscopic ultrasound-guided interventions: novel applications, potential complications and radiologic assessment

Endoscopic ultrasound (EUS)-guided drainage procedures are an increasingly utilized minimally invasive alternative to percutaneous or surgical management strategies, having been shown to decrease recovery time, cost, and duration of hospital stay. The current mainstay of EUS-guided drainage procedures is in pancreatic and peripancreatic collections in pancreatitis. Recent technological advancements and the development of specialized stents have allowed for novel applications in a growing variety of clinical scenarios, including biliary obstruction, cholecystitis and gastrointestinal obstruction. An overview is provided of standard EUS-guided lumen-apposing metal stent (LAMS) management in pancreatic collections, including the expected radiologic findings and appropriate post-treatment sequelae. Relevant parameters to report include presence of a walled-off collection, collection contents, proximity of the target collection to the gastrointestinal lumen, intervening vascular structures or vascular malformations, and presence of regional cystic structures. Novel stent applications in biliary and gastrointestinal drainage are summarized and examples are provided, including choledochoduodenostomy in biliary obstruction, cholecystogastrostomy in cholecystitis, and jejunogastrostomy in focal gastrointestinal obstruction. Finally, a pictorial review of imaging findings of complications including perforation, hemorrhage, displacement, occlusion, migration and mistargeting is provided. Minimally invasive EUS-guided endoluminal stenting is utilized in a growing variety of clinical applications. Radiologist familiarity with common and novel applications of EUS-guided stenting is invaluable in determining suitability for endoscopic management, evaluating treatment response and identifying potential complications.

Role of pancreatography in the endoscopic management of encapsulated pancreatic collections – review and new proposed classification

Pancreatic fluids collections are local complications related to acute or chronic pancreatitis and may require intervention when symptomatic and/or complicated. Within the last decade, endoscopic management of these collections via endoscopic ultrasound-guided transmural drainage has become the gold standard treatment for encapsulated pancreatic collections with high clinical success and lower morbidity compared to traditional surgery and percutaneous drainage. Proper understanding of anatomic landmarks, including assessment of the main pancreatic duct and any associated lesions – such as disruptions and strictures – are key to achieving clinical success, reducing the need for reintervention or recurrence, especially in cases with suspected disconnected pancreatic duct syndrome. Additionally, proper review of imaging and anatomic landmarks, including collection location, are pivotal to determine type and size of pancreatic stenting as well as approach using long-term transmural indwelling plastic stents. Pancreatography to adequately assess the main pancreatic duct may be performed by two methods: Either non-invasively using magnetic resonance cholangiopancreatography or endoscopically via retrograde cholangiopan-creatography. Despite the critical need to understand anatomy via pancrea-tography and assess the main pancreatic duct, a standardized approach or uniform assessment strategy has not been described in the literature. Therefore, the aim of this review was to clarify the role of pancreatography in the endoscopic management of encapsulated pancreatic collections and to propose a new classification system to aid in proper assessment and endoscopic treatment.