Endoscopic ultrasonography-guided rendezvous and fine-caliber multi-hole metal stent for postoperative pancreatic anastomotic stricture

Abstract

Figures

Preprocedural imaging. a Contrast-enhanced computed tomography showing pancreatic duct dilatation distal to the anastomosis with peripancreatic fluid collection consistent with acute pancreatitis. b Endoscopic ultrasonography demonstrating a dilated pancreatic duct distal to the anastomosis.

EUS-guided rendezvous placement of a plastic pancreatic stent across the anastomotic stricture. a Pancreatography after puncture showing the dilated pancreatic duct distal to the anastomosis. b A guidewire advanced into the stomach via the anastomosis. c Placement of a plastic pancreatic stent across the anastomotic stricture using the rendezvous approach. d The 0.025-inch guidewire was grasped with biopsy forceps and carefully drawn into the working channel. e With the rendezvous technique, a catheter was advanced across the anastomosis over the guidewire. f A plastic pancreatic stent was placed across the anastomosis. EUS, endoscopic ultrasonography.

Serial endoscopic and fluoroscopic findings during treatment. a An endoscopic view of the stenotic postoperative anastomosis. b Pancreatography demonstrating upstream pancreatic duct dilatation. c A fluoroscopic image showing plastic stent placement across the anastomosis. d An endoscopic view after plastic stent placement across the anastomosis. e Pancreatography after plastic stent removal showing improved pancreatic duct dilatation. f A fluoroscopic image showing the deployment of the MHSEMS across the anastomosis. g An endoscopic view after MHSEMS deployment across the anastomosis. h Pancreatography after MHSEMS removal showing the resolution of pancreatic duct dilatation. i An endoscopic view of the patent anastomosis after MHSEMS removal.

Full text

Endoscopic treatment for postoperative pancreatic anastomotic strictures is challenging 1 2 . Difficulty in identifying the anastomotic site and the need for repeated plastic stent exchanges further complicate treatment 2 . In such cases, treatment that ensures reliable access to the anastomotic site and directly improves the stricture itself is required 3 4 . Here, we report a case in which an endoscopic ultrasonography (EUS)-guided rendezvous technique successfully secured pancreatic duct access, enabling the effective treatment of a postoperative anastomotic stricture using a novel fine-caliber, multi-hole self-expandable metal stent (MHSEMS). A 73-year-old man who had undergone middle pancreatectomy with gastro-pancreatic anastomosis 15 years earlier presented with abdominal pain. Computed tomography suggested pancreatitis due to an anastomotic stricture ( Fig. 1 ). Pancreatic duct stenting was unsuccessful, and he was referred to our hospital. An EUS-guided rendezvous procedure was performed. Using a 22-gauge FNA needle, the dilated distal pancreatic duct was punctured, and a 0.018-inch guidewire was advanced distally. A double-lumen catheter was used to redirect a 0.025-inch guidewire across the anastomosis and into the stomach. A duodenoscope (TJF-290; Olympus, Tokyo, Japan) was then used to complete the rendezvous and placed a 7 Fr plastic pancreatic stent ( Fig. 2 ). One month later, the plastic stent was exchanged for an MHSEMS (6 mm × 8 cm; Hanarostent Biliary Multi-Hole Benefit; M.I. Tech, Pyeongtaek, South Korea) using a therapeutic gastroscope (GIF-290T; Olympus, Tokyo, Japan). Two months later, the MHSEMS was removed easily using grasping forceps with a duodenoscope ( Video 1 and Fig. 3 ). The anastomosis remained patent, and the patient remained symptom-free 5 months after stent removal.

Preprocedural imaging. a Contrast-enhanced computed tomography showing pancreatic duct dilatation distal to the anastomosis with peripancreatic fluid collection consistent with acute pancreatitis. b Endoscopic ultrasonography demonstrating a dilated pancreatic duct distal to the anastomosis.

EUS-guided rendezvous placement of a plastic pancreatic stent across the anastomotic stricture. a Pancreatography after puncture showing the dilated pancreatic duct distal to the anastomosis. b A guidewire advanced into the stomach via the anastomosis. c Placement of a plastic pancreatic stent across the anastomotic stricture using the rendezvous approach. d The 0.025-inch guidewire was grasped with biopsy forceps and carefully drawn into the working channel. e With the rendezvous technique, a catheter was advanced across the anastomosis over the guidewire. f A plastic pancreatic stent was placed across the anastomosis. EUS, endoscopic ultrasonography.

EUS-guided rendezvous and MHSEMS dilation for the postoperative pancreatic anastomotic stricture. EUS, endoscopic ultrasonography.Video 1

Serial endoscopic and fluoroscopic findings during treatment. a An endoscopic view of the stenotic postoperative anastomosis. b Pancreatography demonstrating upstream pancreatic duct dilatation. c A fluoroscopic image showing plastic stent placement across the anastomosis. d An endoscopic view after plastic stent placement across the anastomosis. e Pancreatography after plastic stent removal showing improved pancreatic duct dilatation. f A fluoroscopic image showing the deployment of the MHSEMS across the anastomosis. g An endoscopic view after MHSEMS deployment across the anastomosis. h Pancreatography after MHSEMS removal showing the resolution of pancreatic duct dilatation. i An endoscopic view of the patent anastomosis after MHSEMS removal.

This 6 mm MHSEMS achieved effective dilation of a postoperative pancreatic anastomotic stricture. Its design could reduce the risks of pancreatitis and migration. The combination of the EUS-guided rendezvous technique allows more reliable treatment of pancreatic duct anastomotic strictures.

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