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[EUS-guided drainage of the pancreatic duct (EUPD)--promising therapeutic alternative to surgical intervention in case of symptomatic retention of the pancreatic duct and unsuccessful ERP].

BACKGROUND
Transpapillary ERP is the gold standard in symptomatic retention of the pancreatic duct or pancreatic fistula; however, it fails in 5-10 % due to a papilla which cannot be reached or cannulated, or in postoperative changes which do not allow conventional endoscopic drainage.


METHOD
Based on our clinical, endoscopic and EUS-related experience as well as a literature search, EUS-guided pancreaticography and drainage of the pancreatic duct (EUPD) are described as alternative approach i) to symptomatic retention of pancreatic duct, ii) for cases with stenoses of the pancreatic duct and anastomoses which cannot be treated with conventional endoscopy, and iii) for patients with postoperative pancreatic fistula within the diagnostic and therapeutic management, including adequate indication, performance and outcome.


RESULTS
EUPD is indicated in cases with i) altered anatomy of upper GI tract (congenital; papilla or pancreaticoenteric anastomosis), ii) symptomatic retention of pancreatic duct due to changes in peripapillary region or iii) stenosis of pancreatic duct/anastomosis, and iv) if surgical intervention cannot be done with a reasonable risk-benefit ratio. EUPD can provide a success rate of 25 to 92 %, a complication rate of 14 to 40 % (bleeding, perforation, pancreatitis, pain) and long-term clinical success rate of 69 to 78 % (pain-, symptom-free). Advantages are sustained endoscopic methodological variability, minimal invasiveness, improvement in quality of life, possible endoscopic revision of complications and conventional endoscopic equipment. In contrast disadvantages include high level of expertise, only low case load, long learning curve, instruments needing further optimisation, and a still not good clinical success rate of 70 % as well as status as an experimental clinical method.


CONCLUSION
With adequate experience EUPD is for carefully selected patients an uncomplicated, elegant and safe method and represents an alternative therapeutic option for the interventional endoscopist allowing more invasive procedures to be avoided. Further prospective and systematic evaluations and technical refinements of EUPD-associated results are needed in order to establish general therapeutic guidelines on indications, peri-interventional management and to define a practical guideline-relevant procedure.