Acute pancreatitis due to afferent loop obstruction treated by endoscopic ultrasound-guided transpancreatic afferent limb drainage

Abstract

Figures

Computed tomography performed 3 months before admission and at the time of hospitalization: a pancreatic parenchymal atrophy 3 months before admission (yellow arrow); b swelling of the pancreatic parenchyma and dilated main pancreatic duct (yellow arrowhead); c, d dilation of the afferent loop at the blind end.

a–d Placement of a plastic stent and a nasodrainage tube into the dilated afferent loop at the blind end via the main pancreatic duct using endoscopic ultrasound-guided transpancreatic afferent limb drainage. a Under EUS guidance (UCT260; Olympus Co., Ltd, Tokyo, Japan), a 19-gauge needle (SonoTip Pro Control; Medico’s Hirata Inc., Osaka, Japan) was inserted into the dilated main pancreatic duct. b A 0.025-inch guidewire (Visiglide2; Olympus) and an MTW catheter (ABIS, Tokyo, Japan) were advanced across the pancreaticojejunal anastomosis into the blind end. c The fistula was dilated using a drill dilator (Tornus ES; Asahi Intecc, Aichi, Japan). d A plastic stent (6-Fr 7-cm, pigtail type, Zimmon; COOK Medical, Bloomington, IN, USA) and a nasodrainage tube (5Fr; Create Medic) were placed into the dilated blind end. EUS, endoscopic ultrasound.

Schematic illustration of EUS-guided afferent limb drainage via the main pancreatic duct. EUS, endoscopic ultrasound.

Full text

Afferent loop obstruction (ALO) is a rare mechanical complication occurring in 0.3–1.0% of patients after gastrectomy 1 . Elevated intraluminal pressure in the afferent loop can lead to cholangitis or pancreatitis. Recently, endoscopic transluminal stent placement using balloon-assisted endoscopy 2 or endoscopic ultrasound (EUS 3 ) has been reported as an effective treatment. We describe the first successful case of the endoscopic treatment of ALO complicated with acute pancreatitis by an EUS-guided transpancreatic approach ( Video 1 ).

Endoscopic ultrasound-guided transpancreatic afferent limb drainage.Video 1

A 71-year-old woman with a history of gallbladder cancer who had undergone pancreaticoduodenectomy 5 years earlier presented with fever and abdominal pain. Computed tomography revealed dilation of the afferent limb and pancreatic enlargement with dilation of the main pancreatic duct (MPD) to 6 mm, compared with images obtained 3 months earlier ( Fig. 1 ). She was diagnosed with acute pancreatitis secondary to ALO.

Computed tomography performed 3 months before admission and at the time of hospitalization: a pancreatic parenchymal atrophy 3 months before admission (yellow arrow); b swelling of the pancreatic parenchyma and dilated main pancreatic duct (yellow arrowhead); c, d dilation of the afferent loop at the blind end.

A short-type double ballon endoscope (EI-580BT; Fujifilm, Tokyo, Japan) reached the choledochojejunal anastomosis; however, the dilated blind end where the pancreaticojejunal anastomosis was located could not be accessed due to peritoneal dissemination. Histopathological examination of endoscopic biopsy specimens revealed adenocarcinoma. As a result, decompression of the afferent limb was not achieved, and only biliary stents were placed. Consequently, we planned to perform EUS-guided transpancreatic afferent limb drainage. Under EUS guidance, a 19-gauge needle was inserted into the MPD, and a guidewire was advanced across the pancreaticojejunal anastomosis into the blind end. There was no pancreatic duct stricture. The fistula was dilated using a drill dilator. A plastic stent and a nasodrainage tube were placed into the dilated blind end ( Fig. 2 ). Six days after the procedure, the nasodrainage tube was removed because both afferent loop dilation and pancreatitis improved promptly ( Fig. 3 ). No recurrence of pancreatitis was observed without removing the stent until the patientʼs death.

a–d Placement of a plastic stent and a nasodrainage tube into the dilated afferent loop at the blind end via the main pancreatic duct using endoscopic ultrasound-guided transpancreatic afferent limb drainage. a Under EUS guidance (UCT260; Olympus Co., Ltd, Tokyo, Japan), a 19-gauge needle (SonoTip Pro Control; Medico’s Hirata Inc., Osaka, Japan) was inserted into the dilated main pancreatic duct. b A 0.025-inch guidewire (Visiglide2; Olympus) and an MTW catheter (ABIS, Tokyo, Japan) were advanced across the pancreaticojejunal anastomosis into the blind end. c The fistula was dilated using a drill dilator (Tornus ES; Asahi Intecc, Aichi, Japan). d A plastic stent (6-Fr 7-cm, pigtail type, Zimmon; COOK Medical, Bloomington, IN, USA) and a nasodrainage tube (5Fr; Create Medic) were placed into the dilated blind end. EUS, endoscopic ultrasound.

Schematic illustration of EUS-guided afferent limb drainage via the main pancreatic duct. EUS, endoscopic ultrasound.

EUS-guided transpancreatic afferent limb drainage may represent a feasible and effective endoscopic treatment for ALO associated with acute pancreatitis.

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