Ultrasound in Wirsung Duct Percutaneous Interventions - SD

Introduction

Hello everybody.

I'm Mal has Ari Radiologist from Georgia.

I work at Pel State Medical University.

Pel is the capital of Georgia.

Today we'll have a talk about vision duct interventions, which we perform under ultrasound guidance, so ultrasound and vision duct percutaneous interventions.

Pancreatic Anatomy Review

Let's review some anatomy.

As we remember, the pancreas is located deep in the body, in the retroperitoneum, just anteriorly to the major vessels and posteriorly to the stomach.

So, as you'll see here, it's horizontally oriented and slightly oblique position, having pancreatic head more coly and tail more cranial.

This is actually the zu duct, how it joins the CBD and joins the pape of water.

Today we'll have a talk about the interventions on Zu duct, which travels in the mid portion of the pancreatic tissue.

Here we can see the anatomy, cross-sections, and this is the most cow one you see here.

The, just the uncinate process.

This is the pancreatic head.

You see here the portal confluence and splenic vein.

When we go slightly upwards cran, we can see the whole pancreatic body.

And finally, in the most cranial portion, most cranial cut of this anatomy images, you can see the distal portion of the body and the pancreatic tail, which reaches the spleen.

If we take the sagittal cuts, and this is the pancreatic head lying anteriorly to the, on the, actually on the anterior surface, touching the anterior surface of the wall of the IVC.

And you can find here on a small area where we have small gap to reach the pancreatic head.

But it's not good to assess the pancreatic duct here because it's the very distal portion of it.

If we go slightly, go slide to the left, you see here the aorta celiac pointing to the pancreatic body.

And you can see here the bowel, large bowel.

And this is the stomach.

So actually no assess is seen here.

If we go more left, you can see here the pancreatic body or, they just, the proximal portion of the tail, which, and you can see here the kidney and stomach again.

And, we take most left cut and the exhale, the sagittal cut.

When we can, we start seeing spleen and small portion of pancreas here.

So seems like there is no possibility to approach the reason duct from, taking in consideration this anatomy slides.

So lecture is about reasoning duct interventions and the ultrasound guidance.

So what should we do? Should we stop at this point?

'cause No, we should keep in mind the normal anatomy variants which are not rear sometimes.

Pancreas is located just behind the left lobe, posterior surface of the liver, left lobe, which enables to reach it using trans hepatic approach.

In some cases, we can see pancreas immediately after anterior abdominal wall, so it makes it possible to assess it percutaneous limb.

Of course we should keep in mind that anatomy may change due to presence of some pathology like pseudocyst or necrotic pancreatic fluid collection, which can interrupt the anatomy and push away the stomach and bowel and enable us to assess the pancreas.

And finally, we should not exclude the transgastric root of vision duct assess.

Indications for Percutaneous PD Access

What are the indications for vision duct? Percutaneous assess, of course, it's dilation.

If it's manifested clinically and cannot be managed conservatively, what might be the cause of this?

So it might be due to pancreatitis when swell pancreas pushes, stops, the reason duct or v duct calculate it might be due to pancreatic head tumor or some ext extreme extrinsic factors like CBD calculate, retroperitoneal tumor, lymph node package, et cetera.

What is the aim of such intervention? I mean, interventional vision duct, first of all, we decompress the vision duct.

Performing such intervention, we can eliminate the clinic of pancreatitis.

We prepare the patient for vision duct patency, possible percutaneous restoration, so we can plan the restoration of vision duct patency, which might be performed Percutaneous Pancreatic imaging.

Pancreatic Imaging and Ultrasound Guidance

Of course, we know the pancreas might be image and ultrasound on CT MR of course, CTMR are much more informative in pancreatic imaging.

But ultrasound is great for intervention guidance, and this is the critical in this situation.

Why is ultrasound the imaging guidance technique? Number one? We have several reasons to say.

So. First of all, it's very quick.

It's not connected with ionizing radiation.

It's real time technique.

And in, with same time, we can include not only have the BM mode image, but see the vessels in real time.

We can aim and guide the needle in real time.

We have possibility to perform the procedure in any inline oblique plane, which sometimes it's very important.

It's cost-saving technique.

And of course, it's possibility of combination with oscopy.

So because of this big advantages, ultrasound is very, very useful.

Equipment for Procedures

This is equipment, very simple equipment which we can use for such procedures.

This is ultrasound unit C, army unit and operating table, which moves from the ultrasound area to the fluoroscopy area.

You can see here the probes, which we usually use.

It might be also the linear array for freehand technique.

When we use the convex, we always, we almost always use the needle guide, which adapts, which has adapters, which accepts the different diameter puncture needles.

And this is the set for drainage, for this is the G wire drainage set.

You see here, the puncture needle, which accepts this guidewire according which we insert the drainage catheter in the target.

More and more we use now special set 22 with a, which contains 22 gauge chiba needle for safe sa You'll see here, very nice picture, very nice ultrasound image of normal pancreas.

We see here the anterior abdominal wall is a little portion of the left liver left lobe.

And you see here all the way across, across the anterior, along the anterior surface of the pancreas, you see the stomach, anterior and posterior wall.

So in this case, it'll be difficult to assess the vision duct without penetrating the stomach.

But this is the same areas again, anterior abdominal wall portion of the left liver lobe and anterior surface of pancreas.

And you can see that there is nothing between the liver and pancreas.

In this case, we can assess the pancreatic tissue, resumed duct, avoiding the stomach.

Some cases with pancreatic duct resumed duct dilation.

This is due to pancreatitis.

The swell pancreatic head stops the zu duct here.

Because of this, it's dilated.

In this case, the zu duct dilation is caused by calculus.

And you note that there is nothing between liver posterior surface and pancreas.

No stomach is seen between them.

In this case, you see the dilated.

This is the CT image, dilated vision duct.

We placed the CBD stent to this patient.

And, as you see here, it seems like it's difficult to assess the vision duct without penetrating stomach.

This is one more case with severely dilated pancreatic duct due to acute pancreatitis.

And you see anterior and posterior walls of stomach and located anteriorly between pancreas and anterior abdominal wall.

Case Presentations

Case 1: Acute Pancreatitis with Necrotic Fluid Collection

Now I'd like to present some cases, which can show the possibility of panc of ultrasound in vision duct intervention.

This patient had acute pancreatitis.

He patient presented with severe pain and dehydration due to nausea and vomiting.

Necrotic fluid collection was detected in pancreatic head area.

Mechanical patient had mechanical jaundice, so the necrotic fluid collection stopped the CBD and severe dilation of visual duct has been detected.

What kind of procedures we perform to him, it was PTC was done.

We performed cysto, stomach, necrotic, necrotic fluid collection drainage has been performed to him.

And finally we do, we did transgastric with Z ostomy.

You can see all those procedures in real time.

This is the gallbladder.

We assessed it by percutaneous puncture.

We are injecting now the contrast.

And finally, pigtail catheter is placed in the gallbladder.

Now we assess the pancreatic head necrotic fluid mass, which is opacified after the catheter placement.

And we rinse it under ultrasound kinase.

We see we are injecting saline and aspirating it back.

And finally we perform to this patient.

Sto you see here is the anterior and posterior walls of stomach, and this is our puncture needle.

By the way, the stomach creates the problem for puncture, causing the change of direction of the needle.

You see how it needle changed the direction.

This is the needle guide and it's out of this trace.

So we needed to withdraw the needle and to perform it a second or probably third time.

Also. This is the tip of the needle.

It looks like it's in the, but we should to get content of vi pancreatic juice in it so we are sure that we are incorrect place.

Finally, we succeed to puncture the visual duct.

We place the drainage catheter and you see now histography, we inject the contrast, which pacifies the whole visual duct, and when we create the pressure, it can also reach the duodenum.

So, this is post-procedure CT of this patient.

You can see here the drainage catheter, which passes through the anterior abdominal wall, passes the anterior and posterior walls of the stomach and it's placed in the vi duct.

They see the 3D reconstruction.

You see the PTC catheter located in gallbladder where you see the vision duct drainage catheter.

And this is the catheter which was placed in necrotic fluid collection due pancreatic due to pancreatitis.

When we inject the contrast in the PTC catheter, you can nicely depict all the anatomy of the biliary tree with the problem here, very distally.

And this is the image when we injected the contrast through the v gusto catheter.

So results in of our intervention.

No procedural complications were observed.

Clinic of acute pancreatitis eliminated and patient's general condition improved dramatically.

Subsequently, patient underwent a successful surgery.

Case 2: Unresectable Malignant Blockage

The second patient with un with unresectable malignant block of duct and biliary tract.

Also PTC with subsequent CBD stenting has been performed to this patient eight months ago.

And then he presented with abdominal pain, irradiating in back nausea and vomiting.

Duodenal obstruction has been excluded by CT with oral contrast.

Zoom dunked was dilated enzymes elevated.

So, the manifested clinical findings were due to pancreatitis.

So what kind of procedures were performed to this patient?

First of all, we drained the vision duct, and after this VZ duct, percutaneous endoluminal, RFA and stenting has been performed.

This is the CT image.

You'll see here the oral contrast, which enabled us to exclude the duodenal obstruction.

In this picture we can see that looks like we cannot avoid the stomach for the this puncture, but due to possibility of imaging in any oblique plane by ultrasound, we managed to avoid the stomach using ultrasound guidance for puncture.

This is the procedure of vi duct RFA and stenting, which was performed in two weeks after vi zoom gusto procedure, you see here the pancreas with no dilation and no s duct dilation.

And now we inject the contrast.

You see here the stent, metallic stent.

This is PTC catheter and we inject the contrast wire STO catheter, then we advance the guide wire, we withdraw the draining drainage catheter, and now we are trying to conduct the guiding catheter, G wire, and then guiding catheter into the duodenum.

So we were successful.

We have to document it, injecting contrast that we are in correct place and that we haven't penetrated the vision duct.

And now we are advancing the RF device.

Note this tiny electrode, this is bipolar RF device which can process the block.

We apply RF energy and then we finally, after RF processing, we put the six millimeter balloon expandable stand, which is expanded in the distal portion of ZO duct.

You can see this process in real time.

So this stent is expanded, then we withdraw the balloon, replace the drainage catheter and perform the fist holography to document the restored patency of the duct.

You can see now how we inject the contrast, which reaches immediately without any problem.

The duodenum, you can see the all the way approximately the restored, the rhythm duct, the patency of which has been restored.

So results again, no procedural complications were observed.

On the rhythm gusto, immune after rhythm gusto procedure and subsequent RFA processing and stenting clinic of pancreatitis eliminate eliminated has been eliminated immediately after vision ostomy.

Procedure, patient died with patent biliary and vision duct stents in four months after vision duct, RFA and stenting.

Case 3: Acute Calculus Pancreatitis

The next patient had acute calculus pancreatitis.

Patient presented with abdominal pain, nausea, vomiting.

Patient was dehydrated in a very poor general condition.

MRCP revealed swelled pancreas and dilated pancreatic duct with some defects of filling in it.

So we suggested the presence of stones and ultrasound revealed with Z eis.

So what kind of procedures we performed through this patient?

First of all, we do, we z ostomy.

We assess the VI duct and drain it.

And then we perform the procedure which I named percutaneous oli Oxy.

Actually, we decided to evacuate the stones in duodenum from vi duct using STO fistula.

We perform it percutaneous and it was performed two weeks after the sto.

This you can see here the MR picture.

This is swelled pancreas with dilated with duct.

MRCP revealed the dilated with duct with some defective fillings here in the mid portion and a distal portion which were due to, happened to be due to stones.

With duct stones.

We performed with Z ostomy and this is the CT after ostomy procedure.

You see our drainage catheter without contrast.

It's without contrast.

You see the drainage catheter here, pigtail catheter, lot of stones located in a distal portion of the vi duct and one stone in the mid portion and a lot of calcifications or embedded stones in the tail of the pancreas.

When we inject the contrast, you can see the v duct, the whole we zoom duct and you can see how contrast reaches duodenum and there is no connection with biliary tree.

So, as the patient become, be, became stable, we decided to try to push down all the stones.

You see this art defect of filling due to stones pushed down all, all the stones into the duodenum and we decided to perform it using a balloon dilation.

You see the dilated balloon in version duct.

And this is the post procedure image showing two dots, which are connected directly with duodenum.

You can see this process in real time.

You can see here the half inflated balloon.

And note how we are pushing down into the duodenum, those stones which are evacuated from here approximately.

I show it again this, these are the stones here, and you can see how we push them down from vi dam ducted into the duodenum.

So this is pre and post procedure picture.

Vision duct contains here the stones and this is this con its connection with duodenum.

But after the procedure we, we are starting, we are starting seeing another duct, which is also connected with the oden.

Actually we made the dilation and umlet xi procedure using this duct, which is probably duct.

And this is Santorini accessory pancreatic duct post-procedure CT control.

We did post-procedure CT control and we found only one stone.

Here. You see nicely it here.

Unfortunately we failed conducting this down because it sort of embedded in the pancreatic tissue.

This is CT control in two months, follow up CT control in two months before we withdraw the drainage catheter.

So we kept this catheter in the vision duct in case of any problem to have assessed to have immediate access to open it.

And it was kept closed for two months.

Then we performed the ct control and we can see the patent version duct and we catheter was withdrawn.

And this is the ultrasound follow up in three months after catheter withdrawal.

You can see the pancreatic tissue, no dilation, no rhythm duct dilation, but still this embedded stone is in the very distal portion of rhythm duct or we can see that it's in a pancreatic head tissue.

So results, no procedural complications again on smy and subsequent oli loy were observed.

Clinic of pancreatitis eliminated immediately after V duct drainage stones removal enabled to withdraw the drainage catheter.

And patient stable is stable during 14 months after the catheter withdrawal.

Conclusion

So I'd like to conclude That ultrasound is the best technique for vision duct percutaneous Assessment, percutaneous vision ostomy, including the technique of duct transgastric assess, is a safe and effective technique.

It should be suggested as a routine treatment option of acute obstructive pancreatitis.

Combined ultrasound fluoroscopy guidance is the most efficient technique for V duct drainage.

Percutaneous visual ostomy enables to create a basis for subsequent duct patency restoration procedures, such procedures like stenting or endoluminal, RFA and stenting, or even percutaneous al ap.

Thank you for your attention.