Endoscopy 2021; 53(04): E134-E135
DOI: 10.1055/a-1216-0593
E-Videos

Piercing technique for recanalization of pancreaticojejunal obstruction through the endoscopic ultrasound-guided pancreatic duct drainage route

Tatsuya Ishii
Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
,
Tsuyoshi Hayashi
Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
,
Kuniyuki Takahashi
Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
,
Toshifumi Kin
Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
,
Akio Katanuma
Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
› Author Affiliations
 

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.


Quality:

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.

Zoom Image
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]).

Zoom Image
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.
Zoom Image
Fig. 3 Magnetic resonance cholangiopancreatography (MRCP) image before the onset of pancreatitis.
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Fig. 4 Radiographic image showing a transmural stent placed between the jejunum and the stomach.
Zoom Image
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.

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Competing interests

A. Katanuma has received lecture fees from Olympus Co., Tokyo Japan; he is currently an Associate Editor for Digestive Endoscopy. The remaining authors declare that they have no conflict of interest.

Acknowledgments

We thank Dr. Edward Barroga (http://orcid.org/0000-0002-8920-2607), Medical Editor and Professor of Academic Writing at St. Luke’s International University for reviewing and editing the manuscript.


Corresponding author

Tatsuya Ishii, MD
Center for Gastroenterology
Teine Keijinkai Hospital
1-40, 12-chome, 1-jou, Maeda, Teine-ku
Sapporo 006-8555
Hokkaido
Japan   
Fax: +81-11-6852967   

Publication History

Publication Date:
05 August 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
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.
Zoom Image
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.
Zoom Image
Fig. 3 Magnetic resonance cholangiopancreatography (MRCP) image before the onset of pancreatitis.
Zoom Image
Fig. 4 Radiographic image showing a transmural stent placed between the jejunum and the stomach.
Zoom Image
Fig. 5 Endoscopic image 1 month later showing that the stent was present at the end of the jejunum.