Successful removal of a pancreatic duct stone in a patient with Whipple resection, using a short single-balloon enteroscope with a transparent hood

Endoscopic retrograde cholangiopancreatography (ERCP) is a challenging procedure, especially in indications involving the pancreatic duct in patients with Whipple resection [1] [2] [3]. Identification of the pancreaticojejunal anastomotic site is difficult because of the location and small size of the anastomosis, and interference from the jejunal folds. We proposed that a transparent hood would be effective for retraction of the folds to a suitable distance from the intestinal wall. Here, we report on the successful removal of a pancreatic duct stone in a patient with Whipple resection, using a prototype short, single-balloon enteroscope (SBE; working length, 152 cm; outer diameter 9.2 mm; working channel diameter 3.2 mm; SIF-Y0004-V01, Olympus Medical Systems, Tokyo, Japan) with a transparent hood.

A 74-year-old woman admitted for mild acute pancreatitis had a history of pancreaticoduodenectomy for bile duct cancer. Computed tomography revealed the remnant of a dilated pancreatic duct and a stone. A therapeutic intervention involving the short SBE was carried out. The pancreatic duct was successfully cannulated using a standard ERCP catheter and a 0.025-inch guidewire ([Fig. 1], [Video 1]). A pancreatogram confirmed the presence of a stone in the main pancreatic duct ([Fig. 2], [Video 2]). The anastomotic site was dilated using a 6-mm balloon, and the stone was removed from the pancreatic duct with a basket and a retrieval balloon ([Fig. 3], [Video 3]), without any complication. In our patient, the transparent hood was effective in identifying the anastomotic site. We have found that the short SBE can be used as a therapeutic intervention along with various conventional ERCP accessories [4] [5].

Fig. 1 Endoscopic view showing a small pancreaticojejunal anastomotic site in a 74-year-old woman with mild acute pancreatitis and history of Whipple resection.

Fig. 2 Endoscopic retrograde pancreatography through the anastomotic site showing a stone in the remnant of the main pancreatic duct.

Fig. 3 a The anastomotic site was dilated with a 6-mm balloon. b The stone was removed from the pancreatic duct with a basket and retrieval balloon.

Pancreatic duct cannulation was achieved using a standard endoscopic retrograde cholangiopancreatography (ERCP) catheter and a 0.025-inch guidewire.

Pancreatography confirmed the presence of a stone in the main pancreatic duct.

The anastomotic site was dilated using a 6-mm balloon, and the stone was removed from pancreatic duct with a basket and retrieval balloon.

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• References

• 1 Chahal P, Baron TH, Topazian MD et al. Endoscopic retrograde cholangiopancreatography in post-Whipple patients. Endoscopy 2006; 38: 1241-1245
• 2 Farrell J, Carr-Locke D, Garrido T et al. Endoscopic retrograde cholangiopancreatography after pancreaticoduodenectomy for benign and malignant disease: indications and technical outcomes. Endoscopy 2006; 38: 1246-1249
• 3 Kinney TP, Li R, Gupta K et al. Therapeutic pancreatic endoscopy after Whipple resection requires rendezvous access. Endoscopy 2009; 41: 898-901
• 4 Obana T, Fujita N, Ito K et al. Therapeutic endoscopic retrograde cholangiography using a single-balloon enteroscope in patients with Roux-en-Y anastomosis. Dig Endosc In press 2013;
• 5 Yamauchi H, Kida M, Okuwaki K et al. Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy. World J Gastroenterol 2013; 19: 1728-1735