Technical tips for antegrade endopancreatic radiofrequency ablation for severe pancreatojejunal stricture

Abstract

Figures

Antegrade insertion of a pancreatoscope in treatment of pancreatojejunal stricture (PJS) in a patient who had undergone pancreatoduodenectomy 1 year previously.

The stricture is confirmed as being a benign tight PJS.

Endopancreatic radiofrequency ablation (RFA) is attempted.

The pancreatoscope is inserted and dilation of the PJS is achieved without bleeding or perforation.

A plastic stent is deployed.

Full text

Pancreatojejunal stricture (PJS) is one of the late adverse events after pancreatoduodenectomy, and can lead to pancreatitis or endocrine pancreatic insufficiency as complications 1 . PJS is usually treated under enteroscopic guidance 2 , although, because of the relatively low technical success rate and prolonged procedure time, an endoscopic ultrasound (EUS)-guided transluminal approach has recently been developed for pancreatic disease 3 . However, in cases of severe PJS, guidewire passage through the PJS into the intestine under the EUS-guided approach might be challenging, since the PJS site cannot be directly visualized. To overcome this issue, a technique involving antegrade transluminal pancreatoscope insertion has been developed. However, despite successful guidewire passage, PJS dilation might still be challenging because the pushing force might be lower in the EUS-guided approach than the enteroscopic approach. Although electrocautery dilation is a useful technique 4 , recurrence of PJS is possible since the burning effect is small. On the other hand, endobiliary radiofrequency ablation (RFA) can sufficiently burn fibrotic tissue 5 . We herein describe a novel technique for PJS treatment using RFA with a pancreatoscope.

A 77-year-old man had undergone pancreatoduodenectomy 1 year earlier for cholangiocarcinoma. At his current presentation, he was admitted to our hospital for acute pancreatitis due to PJS. First, EUS-guided pancreatic duct drainage using a plastic stent was performed. Then 2 weeks later, PJS treatment was attempted. First, guidewire passage through the PJS into the intestine was attempted, although with no success. Thereafter, a pancreatoscope (eyeMax; Micro-Tech, Nanjing, China) was antegradely inserted ( Fig. 1 ). The stricture was confirmed as being a benign tight PJS ( Fig. 2 ). Next, since the endoscopic retrograde cholangiopancreatography (ERCP) catheter could not be inserted into the intestine through the PJS site, endopancreatic RFA was attempted ( Fig. 3 ). Subsequently, the pancreatoscope was inserted and dilation of the PJS was achieved without bleeding or perforation ( Fig. 4 ). Finally, a plastic stent was deployed ( Fig. 5 ) ( Video 1 ). No recurrence of PJS or adverse events were observed at the 1-year follow-up.

Antegrade insertion of a pancreatoscope in treatment of pancreatojejunal stricture (PJS) in a patient who had undergone pancreatoduodenectomy 1 year previously.

The stricture is confirmed as being a benign tight PJS.

Endopancreatic radiofrequency ablation (RFA) is attempted.

The pancreatoscope is inserted and dilation of the PJS is achieved without bleeding or perforation.

A plastic stent is deployed.

Antegrade endopancreatic radiofrequency ablation for severe pancreatojejunal stricture.Video 1

In conclusion, the presented technique might be useful for the treatment of severe PJS, although further evaluation of additional cases is required to confirm our results.

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