Piercing technique for recanalization of pancreaticojejunal obstruction through the endoscopic ultrasound-guided pancreatic duct drainage route
Endoscopic ultrasound-guided pancreatic duct intervention is considered to be the most difficult procedure and requires various techniques to achieve successful treatment, particularly in patients who have undergone pancreatectomy . We report a case of successful recanalization of a complete anastomotic obstruction after pancreaticojejunostomy using a piercing technique ([Video 1]).
Video 1 Recanalization of a pancreaticojejunal obstruction by puncturing with the stiff back end of a guidewire through the endoscopic ultrasound-guided pancreatic duct drainage route.
A 64-year-old man underwent pancreaticoduodenectomy for a pancreatic neuroendocrine tumor; however, he suffered from recurrent pancreatitis owing to pancreaticojejunostomy dysfunction. Initially, we attempted balloon enteroscopy-assisted endoscopic retrograde pancreatography, but we were unable to locate the anastomosis ([Fig. 1]). We then attempted antegrade stenting from the stomach by endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD), but we could not pass a guidewire through the anastomosis. Therefore, we deployed a plastic stent from the main pancreatic duct to the stomach.
We made a further attempt at recanalization through the EUS-PD route 2 months later. Pancreatography was performed, but no contrast media flowed into the jejunum and the guidewire could not be passed through the anastomosis ([Fig. 2]). We therefore reviewed the computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) images ([Fig. 3]), and considered that the tip of the catheter was directed to the lumen of the jejunal limb, and confirmed that there were no major blood vessels around the anastomosis. Accordingly, we punctured the anastomosis using the stiff back end of a 0.035-inch hydrophilic guidewire (Radifocus; Terumo Corp., Tokyo, Japan) and successfully achieved recanalization. After performing balloon dilation, we placed a plastic stent without any adverse events ([Fig. 4] and [Fig. 5]).
Puncture with the stiff back end of a guidewire has been previously reported as a piercing technique  . In the EUS-PD procedure, recanalization of the complete anastomotic obstruction is key to a successful treatment. Although the use of other imaging modalities to initially confirm the correct piercing direction and ensure that adverse events will be minimal is indispensable, this technique can be an effective tool for patients where recanalization is difficult.
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05 August 2020 (online)
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- 1 Nakai Y, Kogure H, Isayama H. et al. Endoscopic ultrasound-guided pancreatic duct drainage. Saudi J Gastroenterol 2019; 25: 210-217
- 2 Toyonaga H, Hayashi T, Katanuma A. Piercing technique via cholangioscopy for the reconstruction of complete anastomotic obstruction after choledochojejunostomy. Dig Endosc 2020; DOI: 10.1111/den.13664.
- 3 Kim EH, Lee HG, Oh JS. et al. Extraluminal recanalization of bile duct anastomosis obstruction after liver transplantation. J Vasc Interv Radiol 2018; 29: 1466-1471