Endoscopic laser lithotripsy for a pancreaticojejunostomy stricture using a novel ultra-slim cholangiopancreatoscope via an endoscopic ultrasound-guided pancreatogastrostomy route

Abstract

Figures

A 0.025-inch guidewire is deployed along the plastic stent.

Novel pancreatoscope insertion is attempted without tract dilation, and it is successfully inserted into the main pancreatic duct.

Laser ablation for the pancreaticojejunostomy stricture can be easily performed without mucosal injury.

After antegrade laser ablation, stricture resolution is obtained.

A plastic stent is deployed without any adverse events.

Full text

Endoscopic ultrasound-guided pancreaticogastrostomy (EUS-PD) is now attempted for failed endoscopic retrograde cholangiopancreatography (ERCP). After EUS-PD, antegrade procedures such as stone extraction and laser ablation can be tried. However, during antegrade procedures, a pancreatoscope must be inserted into the main pancreatic duct through an EUS-PD route. To insert the pancreatoscope, tract dilation techniques such as balloon dilation and metal stent deployment have been reported 1 2 . In cases of balloon dilation, however, the tract might rupture, and the cost of deploying a metal stent is high. To overcome this, an ultra-slim cholangiopancreatoscope with the unique characteristic of providing the working channel exit at the 3 o’clock position (7.8 Fr, Briview, SeeGen Co., Ltd, Shanghai, China) has become available. Technical tips for antegrade laser ablation of a pancreaticojejunostomy stricture (PJS) using this scope are described.

A 71-year-old man underwent pancreaticoduodenostomy due to pancreatic cancer 1 year earlier. He developed frequent pancreatitis due to a PJS and was therefore admitted to our hospital. First, he underwent EUS-PD using a 7-Fr plastic stent without any adverse events. Two weeks later, antegrade treatment was attempted for the PJS. First, a 0.025-inch guidewire was deployed along the plastic stent ( Fig. 1 ), and the stent was removed. Then, novel pancreatoscope insertion was attempted without tract dilation, and it was successfully inserted into the main pancreatic duct ( Fig. 2 ). The PJS was then identified. Because the probe was extracted from the 3 o’clock position, laser ablation for the PJS could be easily performed without mucosal injury ( Fig. 3 ). After antegrade laser ablation, stricture resolution was obtained ( Fig. 4 ). Finally, a plastic stent was deployed without any adverse events ( Fig. 5 , Video 1 ). This patient underwent stent removal after 3 months, with no stricture recurrence observed during the clinical follow-up.

A 0.025-inch guidewire is deployed along the plastic stent.

Novel pancreatoscope insertion is attempted without tract dilation, and it is successfully inserted into the main pancreatic duct.

Laser ablation for the pancreaticojejunostomy stricture can be easily performed without mucosal injury.

After antegrade laser ablation, stricture resolution is obtained.

A plastic stent is deployed without any adverse events.

Novel pancreatoscope insertion is attempted without tract dilation, and it is successfully inserted into the main pancreatic duct.Video 1

In conclusion, an antegrade procedure using this slim pancreatoscope may be useful because tract dilation is not needed.

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