CC BY-NC-ND 4.0 · Journal of Digestive Endoscopy 2022; 13(03): 199-200
DOI: 10.1055/s-0042-1753498
Endoscopy Video

Anastomotic PJ stricture: EUS-Guided PD Drainage

Goutham Reddy Katukuri
1   Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, Telangana, India
,
Anudeep Katrevula
1   Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, Telangana, India
,
Mohan Ramchandani
1   Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, Telangana, India
,
Sundeep Lakhtakia
1   Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, Telangana, India
,
Nageshwar Reddy Duvvur
1   Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, Telangana, India
› Author Affiliations
 

A 24-year-old female underwent pancreato-duodenectomy for pancreatic head tumor (solid pseudopapillary epithelial neoplasm) 2 years ago and now presented with recurrent epigastric pain for the last 6 months. Magnetic resonance cholangiopancreatography revealed narrowing at the pancreato-jejunal (PJ) anastomosis with dilated upstream main pancreatic duct ([Fig. 1]). Attempt at an enteroscopy-guided drainage of pancreatic duct (PD) was unsuccessful due to failure ([Fig. 2]) to reach the anastomotic site. Hence, endoscopic ultrasound (EUS)-guided PD drainage was considered ([Video 1]). At EUS, pancreas echotexture was normal with irregular and dilated PD (6.6 mm in body). The PD was punctured in body region at its maximum diameter with a 19G needle (EZShot3Plus, Olympus, Tokyo, Japan). Pancreatogram confirmed dilated PD with anastomotic PJ stricture with minimal opacification of jejunum ([Fig. 3]). A 0.035” hydrophilic guidewire (Terumo, 260cm) was passed across the PJ stricture into jejunum ([Fig. 4]). The gastro-pancreatic fistula was created by passing 6Fr cystotome over-the-wire. The guidewire was then exchanged for a longer stiffer wire (Jagwire, 0.035,” 450cm, Boston-scientific, Massachusetts, United States). The PJ stricture was dilated with balloon (4mm, Titan, Cook Medical, Indiana, United States) ([Fig. 5]) followed by a 7Fr 12 cm straight plastic stent placed with distal stent tip inside jejunum and proximal end in the stomach (gastro-pancreatico-enteroscopy or Ring drainage) ([Fig. 6]). There was no peri-procedure adverse event. Patient is asymptomatic at 11 months of follow-up with stent in situ.

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Fig. 1 MRCP showing narrowing at the pancreato-jejunal (PJ) anastomotic site (blue arrow) with dilated upstream MPD.
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Fig. 2 Attempt at enteroscopy-guided drainage of pancreatic duct was unsuccessful due to failure to reach the anastomotic site.
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Fig. 3 Pancreatogram shows dilated PD with anastomotic PJ stricture.
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Fig. 4 Guidewire passed across PJ stricture into jejunum.
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Fig. 5 Balloon dilatation of PJ stricture.
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Fig. 6 ‘Ring drainage’ or gastro-pancreato-jejunostomy with distal tip of straight plastic stent in jejunum (blue arrow) and proximal end in gastric lumen (orange arrow).

Video 1 Endoscopic ultrasound guided drainage of pancreatic duct (Antegrade approach).


Quality:

EUS-guided PD drainage can be achieved either by rendezvous (in patient having normal surgical anatomy) or antegrade approach (normal or altered surgical anatomy).[1] [2] In antegrade transanastomotic drainage, the distal end of the stent can be positioned in the small bowel and the proximal end in the stomach (i.e., “ring drainage” or gastro-pancreato-jejunostomy).[3] The reported overall technical and clinical success rates of antegrade approach are 89 and 87%, respectively, with an adverse event rate of 12%.[2] We selected a straight plastic stent due to its better push ability (transmission of force) across the pancreatojejunostomy stricture and gastro-pancreatic fistula leaving a substantial length in stomach to prevent inward migration. Also, guidewire can be passed across the lumen of the straight plastic stent for future stent exchange, if required.

EUS-guided pancreatic duct intervention offers an alternative for patients with obstructed PD who have failed established endoscopic techniques for duct drainage.


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Conflict of Interest

None declared.

  • References

  • 1 Widmer J, Sharaiha RZ, Kahaleh M. Endoscopic ultrasonography-guided drainage of the pancreatic duct. Gastrointest Endosc Clin N Am 2013; 23 (04) 847-861
  • 2 Krafft MR, Nasr JY. Anterograde endoscopic ultrasound-guided pancreatic duct drainage: a technical review. Dig Dis Sci 2019; 64 (07) 1770-1781
  • 3 Tyberg A, Sharaiha RZ, Kedia P. et al. EUS-guided pancreatic drainage for pancreatic strictures after failed ERCP: a multicenter international collaborative study. Gastrointest Endosc 2017; 85 (01) 164-169

Address for correspondence

Sundeep Lakhtakia, MD, DM
Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals
Hyderabad, Telangana
India   

Publication History

Article published online:
13 September 2022

© 2022. Society of Gastrointestinal Endoscopy of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Widmer J, Sharaiha RZ, Kahaleh M. Endoscopic ultrasonography-guided drainage of the pancreatic duct. Gastrointest Endosc Clin N Am 2013; 23 (04) 847-861
  • 2 Krafft MR, Nasr JY. Anterograde endoscopic ultrasound-guided pancreatic duct drainage: a technical review. Dig Dis Sci 2019; 64 (07) 1770-1781
  • 3 Tyberg A, Sharaiha RZ, Kedia P. et al. EUS-guided pancreatic drainage for pancreatic strictures after failed ERCP: a multicenter international collaborative study. Gastrointest Endosc 2017; 85 (01) 164-169

Zoom Image
Fig. 1 MRCP showing narrowing at the pancreato-jejunal (PJ) anastomotic site (blue arrow) with dilated upstream MPD.
Zoom Image
Fig. 2 Attempt at enteroscopy-guided drainage of pancreatic duct was unsuccessful due to failure to reach the anastomotic site.
Zoom Image
Fig. 3 Pancreatogram shows dilated PD with anastomotic PJ stricture.
Zoom Image
Fig. 4 Guidewire passed across PJ stricture into jejunum.
Zoom Image
Fig. 5 Balloon dilatation of PJ stricture.
Zoom Image
Fig. 6 ‘Ring drainage’ or gastro-pancreato-jejunostomy with distal tip of straight plastic stent in jejunum (blue arrow) and proximal end in gastric lumen (orange arrow).