Endoscopic ultrasound-guided recanalization of pancreaticojejunostomy anastomotic stricture using a forward-viewing echoendoscope

Abstract

Figures

Computed tomography shows the dilation of the main pancreatic duct (yellow arrowhead).

The opening of the pancreatic duct could not be identified at the pancreaticojejunostomy site.

a A guidewire was left in place at the anastomosis, and the balloon endoscope was withdrawn. b External manual abdominal compression enabled the advancement of the echoendoscope along the guidewire. c The echoendoscope was successfully inserted at the anastomotic site.

a EUS showed the dilated pancreatic duct through the anastomosis. b The pancreatic duct was punctured through the anastomosis. c A 0.025-inch guidewire was inserted into the pancreatic duct. d The tract was dilated using a 4-mm balloon. e A 7-Fr, 7-cm plastic stent was deployed across the anastomotic stricture. f An endoscopic view of the deployed stent. EUS, endoscopic ultrasound

Full text

Endoscopic ultrasound-guided transmural pancreatic duct drainage (EUS-PDD) has become an important alternative when transpapillary or transanastomotic pancreatic duct drainage is technically challenging 1 2 . Recently, forward-viewing echoendoscope (FV-EUS)-guided drainage through the anastomotic site has been reported as a novel EUS-guided drainage technique; however, this approach has rarely been evaluated.

A 69-year-old woman presented with epigastric discomfort 4 years after undergoing subtotal stomach-preserving pancreaticoduodenectomy for a pancreatic head neuroendocrine tumor (NET G1). Computed tomography demonstrated dilation of the main pancreatic duct (15 mm) indicating a pancreaticojejunostomy anastomotic stricture (PJAS; Fig. 1 ). Double-balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography was attempted; however, the opening of the pancreatic duct could not be identified although the scope reached the anastomosis ( Fig. 2 ). Therefore, EUS-guided recanalization using FV-EUS (TGF-UC260J, Olympus, Tokyo, Japan) was planned. With the aid of a guidewire placed near the anastomosis ( Fig. 3 a ) and external manual compression, FV-EUS was successfully advanced to the anastomotic site ( Fig. 3 b, c ). The dilated main pancreatic duct (9 mm) was punctured at the anastomotic site using a 19-gauge needle (Sonotip, Medi-Globe, Achenmühle, Germany), followed by contrast injection to confirm proper puncture ( Fig. 4 a, b ). A 0.025-inch guidewire was advanced into the pancreatic duct ( Fig. 4 c ). The tract was dilated using a 4-mm REN balloon (KANEKA MEDIX, Osaka, Japan; Fig. 4 d ), and finally, a 7-Fr, 7-cm plastic stent was deployed ( Fig. 4 e, f , Video 1 ). The patient’s symptoms improved after the procedure, without adverse events.

Computed tomography shows the dilation of the main pancreatic duct (yellow arrowhead).

The opening of the pancreatic duct could not be identified at the pancreaticojejunostomy site.

a A guidewire was left in place at the anastomosis, and the balloon endoscope was withdrawn. b External manual abdominal compression enabled the advancement of the echoendoscope along the guidewire. c The echoendoscope was successfully inserted at the anastomotic site.

a EUS showed the dilated pancreatic duct through the anastomosis. b The pancreatic duct was punctured through the anastomosis. c A 0.025-inch guidewire was inserted into the pancreatic duct. d The tract was dilated using a 4-mm balloon. e A 7-Fr, 7-cm plastic stent was deployed across the anastomotic stricture. f An endoscopic view of the deployed stent. EUS, endoscopic ultrasound

EUS-guided recanalization of the pancreaticojejunostomy anastomotic stricture using a forward-viewing echoendoscope, including follow-up imaging. EUS, endoscopic ultrasound.Video 1

This case indicated that EUS-guided recanalization of the PJAS using FV-EUS was feasible and safe. Compared with conventional transmural EUS-PDD, EUS-guided recanalization may offer improved safety because the access route is through the PJA rather than through the abdominal cavity and pancreatic parenchyma, if FV-EUS can reach the anastomotic site 3 4 5 . Further studies are required to clarify the safety, feasibility, and long-term outcomes of this technique.

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