S5352 No Window, No Problem: A Novel Trans-Sigmoidal EUS-Guided Approach to Pancreatic Graft Evaluation

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: We present a 50-year-old man 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, 6 passes were made with a 25-gauge SharkCore needle. Adequate core tissue was obtained without immediate complications. Histology showed no features of acute rejection. 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.