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 [1]. 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.
Fig. 1 Image during balloon enteroscopy-assisted endoscopic retrograde pancreatography showing
that the pancreaticojejunal anastomosis could not be found although, from the computed
tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) scans, it was
considered to be located at the end of the jejunum.
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]).
Fig. 2 Radiographic image showing that the tip of the catheter was directed to the lumen
of the jejunal limb, but no contrast media flowed into the jejunum and the guidewire
could not be passed through the anastomosis.
Fig. 3 Magnetic resonance cholangiopancreatography (MRCP) image before the onset of pancreatitis.
Fig. 4 Radiographic image showing a transmural stent placed between the jejunum and the
stomach.
Fig. 5 Endoscopic image 1 month later showing that the stent was present at the end of the
jejunum.
Puncture with the stiff back end of a guidewire has been previously reported as a
piercing technique [2]
[3]. 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.
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
