Endoscopy 2020; 52(02): E66-E67
DOI: 10.1055/a-0999-5120
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic ultrasound-guided pancreatic duct stent placement for symptomatic pancreaticojejunostomy stricture

Joel Fernandez de Oliveira
Division of Endoscopy, Hospital Beneficência Portuguesa, São Paulo, Brazil
,
Karen Costa Carvalho Gon
Division of Endoscopy, Hospital Beneficência Portuguesa, São Paulo, Brazil
,
Fauze Maluf-Filho
Division of Endoscopy, Hospital Beneficência Portuguesa, São Paulo, Brazil
› Author Affiliations
Further Information

Corresponding author

Joel Fernandez de Oliveira, MD, MSc
Division of Endoscopy
Hospital Beneficência Portuguesa
Rua Maestro Cardim 769
São Paulo, SP, 01323-900
Brazil   
Fax: +55-11-35051000   

Publication History

Publication Date:
17 September 2019 (online)

 

A 57-year-old woman underwent a pancreaticoduodenectomy for a duct-type intraductal papillary mucinous neoplasm in the pancreatic head. She presented 3 years later with recurrent episodes of acute pancreatitis, with computed tomography (CT) revealing swelling of the pancreas remnant and dilation of the pancreatic duct, suggesting pancreaticojejunostomy (PJS) stricture. Endoscopic ultrasound (EUS)-guided pancreatic duct drainage was considered as a viable option for patient management ([Video 1]).

Video 1 Endoscopic ultrasound-guided pancreatic duct stent placement for pancreaticojejunostomy stricture.


Quality:

We advanced the echoendoscope into the stomach and identified the 4.6-mm main pancreatic duct ([Fig. 1]). We punctured the pancreatic duct with a 19-gauge flexible needle and performed pancreatography ([Fig. 2]). A 0.025-inch guidewire could not be negotiated across the PJS anastomosis ([Fig. 3]). Next, we inserted a 6-Fr cystotome followed by the deployment of a 5 Fr × 7 cm plastic stent; the proximal extremity of the stent was positioned in the pancreatic duct and the distal end was in the gastric lumen ([Fig. 4]).

Zoom Image
Fig. 1 Endoscopic ultrasound view showing a dilated pancreatic duct (arrow).
Zoom Image
Fig. 2 Endoscopic ultrasound-guided pancreatic drainage performed with a 19-gauge needle (arrow).
Zoom Image
Fig. 3 Attempt to negotiate a 0.025-inch guidewire across the stricture (arrow).
Zoom Image
Fig. 4 Placement of a 5-Fr plastic stent (arrow) from the stomach into the pancreatic duct.

The recovery was uneventful and the patient was discharged 5 days after the procedure. A CT scan 4 months later demonstrated the good position of the pancreatic stent ([Fig. 5]). In the following 6 months, acute pancreatitis did not recur, and amylase and lipase blood levels returned to normal.

Zoom Image
Fig. 5 Computed tomography control demonstrated pancreatic stent (arrow) in a good position.

The incidence of long-term PJS stricture following pancreaticoduodenectomy resection for benign disease ranges from 5 % to 10 % [1] [2]. Surgical reintervention for this adverse event is complex [3]. Therefore, many authors favor less invasive initial approaches, namely enteroscopy-assisted endoscopic retrograde pancreatography (e-ERP).

EUS-guided pancreatic duct drainage has advanced significantly and provides an alternative to e-ERP. In an international multicenter retrospective study, EUS-guided pancreatic duct drainage demonstrated better clinical success (87.5 % vs. 23.1 %) but had a higher mild-to-moderate adverse event rate (35 % vs. 2.9 %) [4].

In conclusion EUS-guided pancreatic duct stent placement is technically challenging but a viable option to treat PJS stricture in symptomatic patients.

Endoscopy_UCTN_Code_TTT_1AS_2AD

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.

This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos


#

Competing interests

None


Corresponding author

Joel Fernandez de Oliveira, MD, MSc
Division of Endoscopy
Hospital Beneficência Portuguesa
Rua Maestro Cardim 769
São Paulo, SP, 01323-900
Brazil   
Fax: +55-11-35051000   


Zoom Image
Fig. 1 Endoscopic ultrasound view showing a dilated pancreatic duct (arrow).
Zoom Image
Fig. 2 Endoscopic ultrasound-guided pancreatic drainage performed with a 19-gauge needle (arrow).
Zoom Image
Fig. 3 Attempt to negotiate a 0.025-inch guidewire across the stricture (arrow).
Zoom Image
Fig. 4 Placement of a 5-Fr plastic stent (arrow) from the stomach into the pancreatic duct.
Zoom Image
Fig. 5 Computed tomography control demonstrated pancreatic stent (arrow) in a good position.