Gel immersion radial incision and cutting for pancreaticojejunostomy anastomotic stricture

Pancreaticojejunostomy anastomotic stricture (PJAS) is a late adverse event after pancreaticoduodenectomy [1] that can lead to pancreatic stones, pancreatitis, and abdominal pain. Radial incision and cutting (RIC) has shown promising results for esophagogastric stricture [2], and its usefulness for refractory PJAS was reported in 2021 [3]. However, there have been only a few cases, and the procedure remains challenging. The advantages of gel immersion endoscopy using a clear gel (VISCOCLEAR; Otsuka Pharmaceutical Factory) have been reported for securing a good visual field, including in endoscopic submucosal dissection [4]. Here, we report a case of PJAS treated by RIC during gel immersion endoscopy.

A woman in her 70s developed PJAS with pancreatic stones following pancreaticoduodenectomy for intraductal papillary mucinous neoplasm. A colonoscope (CH-HQ290ZI; Olympus) was inserted to the afferent loop and endoscopy revealed extreme scarring. Spraying with indigo carmine confirmed the presence of a pinhole PJAS ([Fig. 1]). After guidewire insertion, we dilated the severe stenosis using a spiral drill dilator (Tornus ES for 0.025 inch; Asahi Intecc). Balloon dilation (6 mm REN; Kaneka Medical Products) was performed but as a notch remained despite expansion to 8 atm, gel immersion RIC was attempted ([Video 1]). The gel secured a good visual field, and the air supply was turned off during radial incision and cutting. An ITknife2 (KD-611L; Olympus) was inserted into the stricture and the scar was incised in Endocut mode. Because the anastomosis was wide open using RIC, it was easy to remove the pancreatic stones ([Fig. 2]). Finally, a 7-Fr 5-cm plastic stent was placed and the gel was removed by suction. No adverse events were observed. RIC under gel immersion appears to be a safe and efficient procedure that can eliminate the need for an air supply, prevent an increase in pancreatic duct pressure, and prevent pancreatitis.

Fig. 1 a Endoscopy shows extremely severe scarring at a pancreaticojejunostomy anastomotic stricture with pancreatic stones following pancreaticoduodenectomy for intraductal papillary mucinous neoplasm. b After spraying with indigo carmine, a pinhole pancreaticojejunostomy anastomotic stricture was confirmed. c A notch remained following balloon dilation.

Fig. 2 a View from gel immersion endoscopy before radial incision and cutting. A good field of view was obtained without an air supply. b Endoscopy shows improvement of the stricture, and the pancreatic stones were easily removed.

Video 1 Gel immersion radial incision and cutting (RIC) is safe and efficient for the treatment of pancreaticojejunostomy anastomotic stricture (PJAS).

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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 Muto M, Ezoe Y, Yano T. et al. Usefulness of endoscopic radial incision and cutting method for refractory esophagogastric anastomotic stricture (with video). Gastrointest Endosc 2012; 75: 965-972
• 3 Inoue T, Ibusuki M, Kitano R. et al. Radial incision and cutting combined with balloon dilation for refractory pancreaticojejunostomy anastomotic strictures. Endosc Int Open 2021; 9: E578-E582
• 4 Yano T, Nemoto D, Ono K. et al. Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos). Gastrointest Endosc 2016; 83: 809-811

Publication History

Article published online:
04 May 2023