Endoscopic ultrasound-guided retrograde pancreatic stent placement for the treatment of stenotic jejunopancreatic anastomosis after a Whipple procedure

Endoscopic ultrasound (EUS)-guided [1] [2] or percutaneous [3] rendezvous methods have been used for the treatment of stenosis at the jejunopancreatic anastomosis following pancreatoduodenectomy. However, the use of EUS-guided retrograde pancreatic duct stenting has not been reported, even though it may be preferable from the point of view of complications.

A 50-year-old man, who had been suffering from repetitive pancreatitis for 1 year due to stenosis at the jejunopancreatic anastomosis after pancreatoduodenectomy ([Fig. 1 a]), underwent EUS-guided retrograde pancreatic duct stenting. Prior to the procedure, despite careful searching with a forward-viewing scope, the orifice of the pancreatic duct could not be detected due to severe luminal inflammation. A convex-type EUS scope (GF-UCT240; Olympus, Tokyo, Japan) was advanced to the anastomotic site ([Fig. 1 b]) and, using color Doppler, the puncture line was adjusted to avoid blood vessels. A 19-gauge needle (SonoTip Pro Control; Medi-globe, Achenmühle, Germany) was inserted into the main pancreatic duct ([Fig. 1 c]), and advancement of a guide wire (VisiGlide, 0.025-inch; Olympus) fully into the duct was confirmed using contrast medium ([Fig. 1 d]). Dilation was unsuccessful with a bougie catheter (Soehendra, 4 – 7 Fr; Cook Medical, Winston-Salem, North Carolina, USA), but was easily completed using a diathermic sheath (Cysto-Gastro Set, 6 Fr; Endo-Flex, Voerde, Germany) [4]. A plastic stent (Geenen, 5 Fr; Cook Medical) was placed ([Fig. 1 e]) and the patient’s symptoms disappeared immediately.

Fig. 1 a – e Images of the pancreatitis and the initial procedure: a computed tomography (CT) showing a dilated main pancreatic duct (MPD), fluid collection at the anastomosis (arrowhead), and a thickened jejunal wall (arrows); b scope placed at the anastomosis; c color Doppler image showing the needle striking into the duct (arrow); d plaques visible in the MPD (arrows); e a pancreatic stent placed through the jejunum.

Two months later, as scheduled, the stent was upsized to a 7 Fr with balloon dilation (Quantum TTC, 6 mm; Cook Medical) ([Fig. 2 a]). No complications occurred during these procedures and the patient was subsequently healthy ([Fig. 2 b]).

Fig. 2 a, b The second procedure and following CT: a balloon dilation of the stenotic jejunopancreatic anastomosis for upsizing of the stent; b CT view showing healing of the jejunal and peripancreatic inflammation and the pancreatic stent in place in the nondilated MPD.

Compared with the rendezvous method, the retrograde procedure presented here is a one-step, one-scope method that is not performed through the abdominal cavity; hence, it carries a lower risk of pancreatic juice leakage and other complications [5]. This method is worthwhile when attempting to rescue a stenotic pancreatojejunostomy after a Whipple resection.

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• References

• 1 Kikuyama M, Itoi T, Ota Y et al. Therapeutic endoscopy for stenotic pancreatodigestive tract anastomosis after pancreatoduodenectomy (with videos). Gastrointest Endosc 2011; 73: 376-382
• 2 Mallery S, Matlock J, Freeman ML. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of 6 cases. Gastrointest Endosc 2004; 59: 100-107
• 3 Ota Y, Kikuyama M, Suzuki S et al. Percutaneous pancreatic-duct puncture with rendezvous technique can treat stenotic pancreaticojejunostomy. Digest Endosc 2010; 22: 228-231
• 4 Kawakami H, Kuwatani M, Eto K et al. Resolution of a refractory severe biliary stricture using a diathermic sheath. Endoscopy 2012; 44 (Suppl. 02) E119-120
• 5 Will U, Fueldner F, Thieme AK et al. Transgastric pancreatography and EUS-guided drainage of the pancreatic duct. J Hepatobiliary Pancreat Surg 2007; 14: 377-382