Surgically altered anatomy may complicate retrograde endoscopic pancreatic duct access. Endoscopic ultrasound (EUS)-guided ring drainage has been suggested as an effective alternative for this specific population by providing simultaneous bidirectional trans-anastomotic and transmural drainage using double pigtail plastic stents. Our aim was to evaluate the technical and clinical outcomes of EUS-guided ring drainage in surgically altered anatomy and describe technical aspects of the procedure.

In this retrospective international evaluation, patients from 6 referral centers with surgically altered enteral and/or pancreatic anatomy were included who had undergone EUS-guided ring drainage between 2013 and May 2025. Primary outcome was technical success, secondary outcomes were intra- and postprocedural adverse events. Technical approach and follow-up are furthermore described.

Overall, 58 patients (median age 58 years, IQR 50-65, 47% female) were included in this study. Indication for endoscopic intervention was pain and/or repeated acute pancreatitis in 51 (88%) patients. Most patients had a history of pancreatoduodenectomy (N=43, 74%) and failed enteroscopy-assisted endoscopic retrograde pancreatography (N=22, 38%). Technical success with complete ring drainage was achieved in 51 patients (88%). Technical failures (N=7, 12%) were attributed to failure to manipulate the guidewire across the anastomosis (N=6, 10%) and wire rupture (N=1, 1.7%). In 3 primary technical failures (5.2%), pancreatic duct drainage was achieved via pancreaticogastrostomy, which could be converted to ring drainage in a second procedure. All centers had a similar technical approach with use of a 19G needle for access and 6 French (Fr) cystotome insertion +- balloon dilation for tract preparation and trans-anastomotic access. All ring drainages were performed using double pigtail stents, most common stent diameters were 7 Fr (N=25) and 8.5 Fr (N=24). In 6 patients (8.6%), intraprocedural complications occurred in form of bleeding (N=2, 3.4%), stent dislocation (N=2, 3.4%) and loss of wire access (N=2, 3.4%). Post-procedural adverse events were recorded in 19 patients (32%), namely acute pancreatitis (N=7, 12%), abdominal pain (N=5, 8.6%), bleeding (N=4, 6.9%), leak/exudation (N=2, 3.4%), stent dislocation (N=1, 1.7%) and others (N=3, 5.2%). Clinically, complications were graded AGREE I (N=1, 1.7%), II (N=13, 22%), IIIa (N=4, 6.9%), and IIIb (N=1, 1.7%). One patient (1.7%) underwent surgery after stent dislocation with subsequent intramural gastric hematoma. All other complications were managed conservatively with medical and/or endoscopic treatment. During a median follow-up of 284 (IQR 95-556) days, one patient (1.7%) underwent elective surgery because of insufficient clinical success. Planned endoscopic reintervention was performed in a median interval of 104 (IQR 84-180) days in 41 cases (71%). In 28 patients (48%), final stent extraction was performed after a median interval of 151 (IQR 97-382) days. 

 Our data suggests that EUS-guided ring drainage in surgically altered anatomy is feasible and relatively safe. By providing effective bidirectional drainage using a homogenous technical approach across centerselective conversion to surgery was clinically warranted only in one patient. . Since this procedure is often applied in highly selected cases, prospective randomized studies are unlikely to be performed, but long-term clinical data from larger samples are required to investigate optimal follow up strategies.