Pancreatic antegrade needle-knife (PANK) for treatment of symptomatic pancreatic duct obstruction in Whipple patients (with video)

Background: Endoscopic decompression of symptomatic main pancreatic duct (MPD) dilation in Whipple patients is often difficult because of stenosis of the pancreaticojejunal (PJ) anastomosis.

Objective: To evaluate the feasibility and procedural safety of the pancreatic antegrade needle-knife (PANK) technique, with the goal of restoring antegrade MPD flow, when endoscopic retrograde pancreatography (ERP) and EUS-guided rendezvous fail.

Setting: Tertiary care center.

Design: Retrospective series.

Patients: Three patients with symptomatic MPD dilation refractory to ERP and EUS-guided rendezvous.

Interventions: Under EUS guidance, a 19-gauge echo-needle was used to gain access to the dilated MPD and a Jagwire advanced. After failed attempts at antegrade guidewire passage across the PJ stenosis, deep transgastric MPD access was achieved via a Soehendra stent retriever and balloon dilation. Careful antegrade needle-knife of the stenotic site was performed. A long pancreatic stent spanning the jejunum, MPD, and gastric access site was placed. Four to 8 weeks later, this stent was upsized and converted to a PJ stent, which in turn was removed 4 weeks thereafter.

Main outcome measurements: Technical feasibility and complications.

Results: All 3 patients successfully underwent the PANK procedure. Pre- and post-MRCP studies showed the mean MPD diameter decreased 60% from 8.3 mm to 3.6 mm (mean follow-up 8 months). At 24-month follow-up, all 3 patients experienced decreased or resolved pain without further need for MPD intervention.

Limitations: Retrospective study with small numbers.

Conclusions: When ERP and EUS rendezvous fail, the PANK procedure using a staged stent strategy seems to be an effective means of MPD decompression.