Forward-viewing echoendoscope-guided pancreaticojejunostomy for post-pancreaticoduodenectomy stricture

Abstract

Figures

Pancreatic fistula (red circle) near the pancreaticojejunostomy site.

Endoscopic ultrasound-guided rendezvous technique and EUS-guided pancreatic fistula drainage. a Pancreatic duct puncture via the stomach and contrast medium injection. b Only the pancreatic fistula is visualized from the pancreatic duct. c Guidewire advancement stops at the pancreaticojejunostomy site and advances only to the pancreatic fistula. d Puncture of and contrast medium injection into the pancreatic fistula via transgastric using EUS. e Guidewire placement in the pancreatic fistula. f Transgastric stent placement in the pancreatic fistula. Abbreviation: EUS, endoscopic ultrasound.

Schema of EUS-guided pancreaticojejunostomy. a Insertion of a forward-viewing echoendoscope into the pancreaticojejunostomy site. b Pancreatic duct puncture. c Guidewire placement in the pancreatic duct. d Puncture site dilation. e Stent placement in the pancreatic duct. Abbreviation: EUS, endoscopic ultrasound.

Endoscopic ultrasound-guided pancreaticojejunostomy. a Insertion of a forward-viewing echoendoscope into the pancreaticojejunostomy site, followed by pancreatic duct puncture using a 19G needle and contrast medium injection. b Guidewire placement in the pancreatic duct. c Puncture site dilation using a drill-type dilator. d Placement of two guidewires using a double-lumen catheter. e Puncture site dilation with a 3-mm balloon dilator. f Stent placement in the pancreatic duct. Abbreviation: EUS, endoscopic ultrasound.

Full text

Pancreaticojejunal anastomotic strictures (PJAS) and pancreatic fluid leakage can occur after pancreaticoduodenectomy 1 2 . Treatments include endoscopic retrograde pancreatography using a balloon enteroscope or transgastric endoscopic ultrasound (EUS)-guided procedures 2 3 . These treatments can be challenging in patients with severe or complete anastomotic obstruction. Alternatively, EUS-guided pancreaticojejunostomy (EUS-PJS) allows direct access to the pancreatic duct 4 , and a forward-viewing echoendoscope (FV-EUS; TGF-UCT260J; Olympus Medical Systems) expands the field of view, facilitating the precise identification of and access to the anastomotic site 4 . Herein, we describe our experience implementing EUS-PJS.

A 76-year-old man presented with PJAS and pancreatic fluid leakage 8 months after pancreaticoduodenectomy ( Fig. 1 ). Endoscopic treatment was planned, but single-balloon enteroscopy could not identify the pancreaticojejunostomy site. An EUS-guided rendezvous technique ( Fig. 2 a ) was attempted, but neither a guidewire (GW) nor contrast medium could pass through the pancreaticojejunostomy site; both advanced into the pancreatic fluid leakage area ( Fig. 2 b, c ). Transgastric EUS-guided drainage was performed for pancreatic fluid leakage on the same day ( Fig. 2 d ). Subsequently, EUS-PJS was performed using FV-EUS ( Fig. 3 , Video 1 ), which was advanced to the pancreaticojejunostomy site. The pancreatic duct was identified using EUS, punctured with a 19 G needle (EZ shot3; Olympus Medical Systems), and confirmed with contrast medium ( Fig. 4 a ), then a 0.025-inch GW was inserted ( Fig. 4 b ). The double-GW technique was employed due to significant angulation of the pancreatic duct, and dilation was performed using a drill-type dilator ( Fig. 4 c ). A double-lumen catheter was inserted while retaining 0.035 inches of GW in the pancreatic duct ( Fig. 4 d ). A 3-mm balloon dilator was used to dilate the pancreaticojejunostomy site ( Fig. 4 e ). A 7Fr 5-cm plastic stent was placed to complete the procedure ( Fig. 4 f ). Postoperative adverse events did not occur. EUS-PJS can treat PJAS if balloon enteroscopy or a transgastric EUS-guided approach is unsuccessful.

Pancreatic fistula (red circle) near the pancreaticojejunostomy site.

Endoscopic ultrasound-guided rendezvous technique and EUS-guided pancreatic fistula drainage. a Pancreatic duct puncture via the stomach and contrast medium injection. b Only the pancreatic fistula is visualized from the pancreatic duct. c Guidewire advancement stops at the pancreaticojejunostomy site and advances only to the pancreatic fistula. d Puncture of and contrast medium injection into the pancreatic fistula via transgastric using EUS. e Guidewire placement in the pancreatic fistula. f Transgastric stent placement in the pancreatic fistula. Abbreviation: EUS, endoscopic ultrasound.

Schema of EUS-guided pancreaticojejunostomy. a Insertion of a forward-viewing echoendoscope into the pancreaticojejunostomy site. b Pancreatic duct puncture. c Guidewire placement in the pancreatic duct. d Puncture site dilation. e Stent placement in the pancreatic duct. Abbreviation: EUS, endoscopic ultrasound.

Endoscopic ultrasound-guided pancreaticojejunostomy. a Insertion of a forward-viewing echoendoscope into the pancreaticojejunostomy site, followed by pancreatic duct puncture using a 19G needle and contrast medium injection. b Guidewire placement in the pancreatic duct. c Puncture site dilation using a drill-type dilator. d Placement of two guidewires using a double-lumen catheter. e Puncture site dilation with a 3-mm balloon dilator. f Stent placement in the pancreatic duct. Abbreviation: EUS, endoscopic ultrasound.

Endoscopic ultrasound (EUS)-guided pancreaticojejunostomy after unsuccessful attempts with a balloon enteroscope and a transgastric EUS-guided approach.Video 1

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