Microcatheter-assisted guidewire manipulation via peroral pancreatoscopy for recanalization of pancreaticojejunostomy obstruction

Abstract

Figures

Initial imaging. a Computed tomography scan showed dilation of the main pancreatic duct. b Attempts to advance the guidewire through the obstruction were unsuccessful.

Successful guidewire placement. a Coordinated manipulation of the guidewire and a 3-Fr microcatheter (Daimon-ERCP-catheter; Hanaco Medical, Saitama, Japan) under the SpyGlass DS digital single-operator cholangioscope (Boston Scientific, Marlborough, Massachusetts, USA) allowed successful penetration of the anastomotic site. b Confirmation of the jejunum using contrast injection through the microcatheter. c The peroral pancreatoscopy image showed the guidewire penetrating the anastomotic site.

Full text

Pancreatojejunostomy stricture is one of the complications after pancreaticoduodenectomy 1 . Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has emerged as an alternative to enteroscopy-guided treatment. We present a case demonstrating the successful coordinated manipulation of a 3-Fr microcatheter and pancreatoscopy for recanalization of a complete pancreaticojejunostomy obstruction.

A 72-year-old man, who had previously undergone pancreaticoduodenectomy for distal bile duct cancer, presented with pancreatitis due to a pancreaticojejunostomy anastomotic stricture ( Fig. 1 a ). As the anastomosis could not be identified by the enteroscopy-guided approach, EUS-PD was performed. The anastomosis was completely stenosed on contrast imaging and an attempt to negotiate the obstruction using a guidewire under fluoroscopic guidance failed; therefore, a plastic stent was deployed in the main pancreatic duct ( Fig. 1 b ).

Initial imaging. a Computed tomography scan showed dilation of the main pancreatic duct. b Attempts to advance the guidewire through the obstruction were unsuccessful.

Another attempt to advance the guidewire through the anastomotic obstruction was unsuccessful 3 months after EUS-PD. A covered metal stent (Hanaro Benefit; Boston Scientific, Marlborough, Massachusetts, USA) was placed over the fistula of the pancreaticogastrostomy. Then, 1 week later, the SpyGlass DS digital single-operator cholangioscope (Boston Scientific) was inserted into the pancreatic duct via the metal stent. However, the obstruction could still not be breached with guidewire manipulation under peroral pancreatoscopy. A 3-Fr microcatheter (Daimon-ERCP-catheter; Hanaco Medical, Saitama, Japan) was then introduced through the pancreatoscope, and guidewire manipulation under the microcatheter enhanced maneuverability, facilitating breakthrough and enabling successful penetration of the anastomotic site ( Fig. 2 ). After confirming the jejunum using contrast injection through the microcatheter, a plastic stent was successfully placed transgastrically to bridge the pancreatic duct and jejunal anastomosis in an antegrade fashion ( Video 1 ).

Successful guidewire placement. a Coordinated manipulation of the guidewire and a 3-Fr microcatheter (Daimon-ERCP-catheter; Hanaco Medical, Saitama, Japan) under the SpyGlass DS digital single-operator cholangioscope (Boston Scientific, Marlborough, Massachusetts, USA) allowed successful penetration of the anastomotic site. b Confirmation of the jejunum using contrast injection through the microcatheter. c The peroral pancreatoscopy image showed the guidewire penetrating the anastomotic site.

3-Fr microcatheter-assisted peroral pancreatoscopy via pancreaticogastrostomy for recanalization of pancreaticojejunostomy obstruction.Video 1

Peroral pancreatoscopy through the pancreaticogastrostomy fistula has been reported as an effective and safe option for antegrade guidewire placement 2 , but challenges persist, particularly when navigating the guidewire through the pancreatoscope. The microcatheter offers distinct advantages, including the ability to obtain selective contrast-enhanced images and enhanced maneuverability of the guidewire for a super-selective approach 3 .

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