Endoscopic ultrasound-guided antegrade dilation using a drill dilator for a pancreatojejunostomy anastomotic stricture, with pancreatoscopic findings

Pancreaticojejunal anastomotic stricture (PJS) occurs as a complication after pancreaticoduodenostomy, with a reported incidence rate of 1.4 %–11.4 % [1]. Because abdominal pain or acute pancreatitis can occur in patients with a PJS, resolution of the PJS is desirable. The endoscopic approach is more often selected because, compared with surgical treatment, it is a noninvasive procedure. Although the enteroscopic approach is usually attempted [2] [3], it has disadvantages such as prolonged procedure time. Accordingly, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has been developed [4]. This alternative method is reported to have a high technical success rate and requires dilation of the PJS. The Tornus ES drill dilator (Asahi Intecc) ([Fig. 1]) has recently become available in Japan [5]. It enables the tract to be easily dilated using a clockwise rotation without any pushing force. We herein describe its successful use for dilation of a PJS, with the pancreatoscopic findings shown.

Fig. 1 Photograph of the Tornus ES drill dilator (Asahi Intecc).

A 77-year-old man was admitted to our hospital with frequent episodes of acute pancreatitis. He had undergone pancreaticoduodenostomy for pancreatic head cancer 6 months previously. Computed tomography revealed a PJS, and EUS-PD with a plastic stent was performed. After 3 months, treatment was attempted for the PJS. The fistula was dilated using a balloon catheter ([Fig. 2]), following which the PJS site was evaluated after antegrade insertion of a pancreatoscope. Pancreatoscopy revealed a tight stricture, but no findings to indicate recurrence of the pancreatic cancer ([Fig. 3]). Because, after a guidewire had been deployed, the endoscopic retrograde cholangiopancreatography catheter could not be inserted into the intestine across the PJS, PJS dilation was attempted using the drill dilator and was easily achieved ([Fig. 4]). Further pancreatoscopy showed resolution of the PJS without any bleeding ([Fig. 5]; [Video 1]). No recurrence of the PJS has been observed during the 12 months following this procedure.

Fig. 2 Fluoroscopic image showing the fistula being dilated using a balloon catheter.

Fig. 3 Pancreatoscopic view of the site of the pancreaticojejunal anastomotic stricture showing a tight stricture, but no findings to indicate recurrence of the pancreatic cancer.

Fig. 4 Fluoroscopic image showing dilation of the pancreaticojejunal anastomotic stricture being attempted and easily achieved using the drill dilator.

Fig. 5 Final pancreatoscopic image showing resolution of the pancreaticojejunal anastomotic stricture with no evidence of bleeding.

Video 1 Endoscopic ultrasound-guided antegrade dilation using a drill dilator for a pancreatojejunostomy anastomotic stricture, with pancreatoscopic findings shown.

In conclusion, the Tornus ES drill dilator may be useful in obtaining resolution of a PJS; however, additional studies with more cases are required.

Endoscopy_UCTN_Code_TTT_1AS_2AD

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Zarzavadjian Le Bian A, Cesaretti M, Tabchouri N. et al. Late pancreatic anastomosis stricture following pancreaticoduodenectomy: a systematic review. J Gastrointest Surg 2018; 22: 2021-2028
• 2 Chen YI, Levy MJ, Moreels TG. et al. An international multicenter study comparing EUS-guided pancreatic duct drainage with enteroscopy-assisted endoscopic retrograde pancreatography after Whipple surgery. Gastrointest Endosc 2017; 85: 170-177
• 3 Matsunami Y, Itoi T, Sofuni A. et al. Evaluation of a new stent for EUS-guided pancreatic duct drainage: long-term follow-up outcome. Endosc Int Open 2018; 6: E505-E512
• 4 Dhir V, Isayama H, Itoi T. et al. Endoscopic ultrasonography-guided biliary and pancreatic duct interventions. Dig Endosc 2017; 29: 472-485
• 5 Ogawa T, Kanno Y, Koshita S. et al. Prospective feasibility study on the efficacy and safety of a novel spiral dilator for endoscopic ultrasound-guided drainage. DEN Open 2022; 3: e170

Publication History

Article published online:
11 April 2023