P5735 - No Window, No Problem: A Novel Trans-Sigmoidal EUS-Guided Approach to Pancreatic Graft Evaluation

Award: ACG Presidential Poster Award

Sushrut Ingawale, MD, DNB, MBBS¹, Kornpong Vantanasiri, MD², Chirag Patel, MD², Maxwell Smith, MD², Terry L.. Jue, MD³
1Quinnipiac University - Frank H Netter MD School of Medicine, Bridgeport, CT; 2Mayo Clinic Arizona, Phoenix, AZ; 3Mayo Clinic Arizona, Scottsdale, AZ

Introduction: Simultaneous pancreas-kidney (SPK) transplantation is a definitive treatment for patients with end-stage renal disease and insulin-dependent diabetes. Early detection of pancreatic allograft rejection is essential to preserve graft function, with percutaneous ultrasound (US)-guided biopsy being the standard diagnostic approach. However, anatomical and technical limitations may render this method unfeasible. Endoscopic ultrasound (EUS)-guided interventions offer a viable alternative, providing real-time imaging and access to deep abdominal structures. While trans-duodenal EUS-guided biopsy has been reported in SPK patients, no literature to date describes a trans-sigmoidal approach.

Case Description/

Methods: We present a 50-year-old male with ESRD secondary to insulin-dependent type 2 diabetes who underwent SPK transplantation. Postoperatively, the patient experienced recurrent elevations in pancreatic enzymes, raising concerns for graft dysfunction. Multiple attempts at percutaneous and CT-guided pancreatic allograft biopsy were unsuccessful, yielding only non-diagnostic tissue. Empiric corticosteroids led to transient improvement, but enzyme elevations recurred. A multidisciplinary review concluded that a transduodenal EUS-guided approach was anatomically unfeasible due to graft positioning. As an alternative, the patient underwent a trans-sigmoidal EUS-guided fine needle biopsy. Using an echoendoscope advanced into the sigmoid colon, six passes were made with a 25-gauge SharkCore needle (Figure 1). Adequate core tissue was obtained without immediate complications. Histology showed no features of acute rejection (Figure 2). A concurrent renal biopsy was also negative for rejection.

Discussion: This case highlights the first reported use of a trans-sigmoidal EUS-guided approach for pancreatic allograft biopsy in an SPK transplant recipient. When conventional biopsy routes are unsuccessful due to anatomical challenges, EUS-guided techniques offer a safe and effective alternative. This novel approach leverages the proximity of the sigmoid colon to low-lying allografts. Key procedural considerations include bowel preparation, Doppler imaging for vascular mapping, and appropriate needle selection. But, the trans-sigmoidal route carries potential risks, such as perforation or infection, necessitating careful patient selection and experienced operators. This case supports the need for further research to establish the safety and reproducibility of this technique for broader clinical use.


Figure: Figure 1: Lower Endoscopic Ultrasound-Guided Fine Needle Aspiration of Pancreatic Allograft
Legend: Lower endoscopic ultrasound (EUS) image demonstrating a 25-gauge SharkCore biopsy needle (arrow) advanced using a transcolonic approach for fine needle aspiration (FNA) and biopsy of the pancreatic allograft. The needle is visualized within the target tissue, allowing for real-time imaging guidance during tissue sampling of the allograft.


Figure: Figure 2: Histologic section of the pancreatic allograft (20x magnification)
Legend: Sections show: benign pancreatic parenchyma composed predominantly of acinar cells without definitive features of acute cellular rejection. Immunohistochemistry for C4d is negative for antibody mediated rejection (not pictured).

Disclosures:
Sushrut Ingawale indicated no relevant financial relationships.
Kornpong Vantanasiri indicated no relevant financial relationships.
Chirag Patel: Roche – Advisory Committee/Board Member.
Maxwell Smith indicated no relevant financial relationships.
Terry Jue: Boston Scientific – Jan 2024, Honorarium received for serving as an Instructor at Fellows' Tissue resection course.

Sushrut Ingawale, MD, DNB, MBBS¹, Kornpong Vantanasiri, MD², Chirag Patel, MD², Maxwell Smith, MD², Terry L.. Jue, MD³. P5735 - No Window, No Problem: A Novel Trans-Sigmoidal EUS-Guided Approach to Pancreatic Graft Evaluation, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.