LAUSR

Disconnected pancreatic duct syndrome (DPDS) is characterized by extraductal leakage of pancreatic juice and destruction of tissue surrounding the pancreas [1]. Many DPDS cases need surgical treatment [2]. Transpapillary pancreatic stenting and endoscopic ultrasound (EUS)-guided transmural drainage of PD and walled-off necrosis (WON) are also reported to be effective for DPDS [2–4]. The EUS-guided rendezvous technique (EUS-RV) was shown to be effective as a salvage procedure to connect to the disruption directly when drainage procedures to treat DPDS proved ineffective. A 60-year-old man suffered from severe pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) for PD stenosis of the pancreatic head. He was transferred to our hospital for further treatment because his WON-related symptoms (▶Fig. 1) had worsened. We performed EUS-guided transmural drainage for the infected WON and percutaneous drainage for the abdominal effusion with a high amylase level. ERCP was performed for drainage to relieve the DPDS. Pancreatography showed only the proximal PD and extravasation of contrast medium in the WON (▶Fig. 2a). A nasocystic tube was placed in the WON via the PD because guidewire negotiation to the distal PD had failed (▶Fig. 2b). Pancreatic juice still leaked, so EUSRV was performed to treat the DPDS (▶Video 1). The PD was punctured transgastrically by a 19-gauge needle (EZ shot 3 Plus; Olympus Medical, Tokyo, Japan), and a 0.025inch hydrophilic guidewire was manipulated through the duodenal papilla along the nasocystic tube (▶Fig. 3a). The echoendoscope was switched to a duodenoscope. The guidewire was grasped and brought into the accessory channel. Another catheter was cannulated over the guidewire to the PD. Finally, an 8.5Fr pancreatic stent (Olympus Medical) was placed across the disconnected PD (▶Fig. 3b). The exudate fluid was markedly reduced with external drainage, so E-Videos