Pancreatic duct obstruction causing symptomatic pain and recurrent pancreatitis, and the disconnected pancreatic duct syndrome with associated pancreatic leakage, represent significant clinical challenges. While endoscopic retrograde pancreatography (ERP) is the standard first-line treatment, it fails in 5-20% of cases due to difficulty in cannulation or surgically altered anatomy. In these patients, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) has emerged as a feasible minimally invasive alternative to surgical or percutaneous drainage. However, comprehensive long-term outcome data and factors predicting success remain limited.

Aim: To evaluate the technical  and clinical outcomes, adverse events, long-term pain relief, and predictors of technical failure for EUS-PDD.

Retrospective analysis of consecutive patients who underwent EUS-PDD at Institute of Gastroenterology, Hyderabad, India, from December 2019 to July 2025. Primary outcome was technical success, defined as successful pancreatography, insertion of pancreatic duct wire and successful stent placement. Secondary outcomes including (1) Clinical success, defined as residual pain ≤2 on the visual analog scale (VAS, 0-10) and no recurrence of obstructive pancreatitis after successful stent placement during the follow-up period; (2) Adverse events, classified according to the American Society for Gastrointestinal Endoscopy (ASGE) lexicon; (3) Re-intervention rate, defined as the need for repeat EUS-PDD procedure in patients who achieved initial clinical success; and (4) Predictors of technical failure. 

105 patients were included: chronic pancreatitis (n=56, 53.3%), disconnected pancreatic duct syndrome (n=34, 32.4%), combined CP-DPDS (n=7, 6.7%), and surgically altered anatomy (n=8, 7.6%). Overall technical success was 87.6% (92/105) and clinical success was 89.1% (82/92). Subgroup analysis demonstrated: chronic pancreatitis 85.7% technical success, DPDS 85.3% , CP-DPDS 100%, and surgically altered anatomy 100%. Adverse events occurred in 13 patients (12.4%), predominantly mild (92.3%) and managed conservatively (90.9%): bleeding 4.8% (5/105), abdominal pain 2.9% (3/105), mild pancreatic leak 4.8% (5/105). No patients required surgery for adverse event management or procedure-related deaths. Long-term pain relief was achieved in 90.8% of patients (59.2% complete relief, 31.6% partial relief), with mean VAS reduction of 6.27 points (83.7% improvement). Stent-free status was achieved in 36.5% of patients. Mean follow-up was 853 days (2.33 years; range 90-1956 days)

EUS-PDD demonstrated high technical and clinical success rates with low adverse event rates and durable long-term pain relief across diverse indications.