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DOI: 10.1055/a-0677-1623
Peroral antegrade pancreatoscopy for pancreaticolithiasis after endoscopic ultrasound-guided recanalization of a complete pancreaticojejunal stenosis
Publikationsverlauf
Publikationsdatum:
10. September 2018 (online)
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Pancreaticoduodenectomy may result in symptomatic pancreaticojejunal stenosis in 2 % – 10 % of cases [1]. As an alternative to surgery, endoscopic pancreatic duct decompression may be performed by retrograde (enteroscopy) or antegrade (endoscopic ultrasound [EUS]-guided transgastric access) approach [2]. The latter is more likely to be technically successful (up to 70 % of cases) [3], and also enables anastomotic recanalization [4]. For pancreaticolithiasis treatment, an antegrade pancreatoscopy procedure has been recently described as feasible and useful [5].
We herein describe the case of a 51-year-old woman who presented with abdominal pain and several episodes of mild pancreatitis in the preceding 12 months. Symptoms were due to a pancreaticojejunal stenosis and obstructing pancreatic ductal stones following a curative pancreaticoduodenectomy performed 8 years earlier ([Fig. 1]). After a previous EUS-guided attempt failed because of complete pancreaticojejunal stenosis, a successful EUS-guided pancreatic recanalization was achieved in June 2017, which enabled the placement of a transgastric indwelling double-pigtail stent across the stenosis ([Fig. 2], [Fig. 3], [Video 1]). The patient became asymptomatic.
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Video 1 Peroral antegrade pancreatoscopy for evaluating and treating pancreaticojejunal stenosis and pancreatic ductal stone.
Qualität:
In March 2018, it was decided to perform a peroral transgastric pancreatoscopy to evaluate a persistent pancreaticojejunal stenosis and treat any remaining ductal stones. After stent removal and endoscopic dilation of the stenosis and gastric tract ([Fig. 4]), a digital single-operator peroral cholangioscope (SpyGlass DS, Boston Scientific, Marlborough, Massachusetts, USA) was inserted through a standard therapeutic duodenoscope into the pancreatic duct until it reached the jejunum ([Fig. 5], [Video 1]). This revealed a fibrotic pancreaticojejunal stenosis, 3 cm in length, and a persistent pancreatic ductal stone, 4 mm in size ([Fig. 6]). Pancreatic ductal clearance was achieved using water irrigation and push-and-pull maneuver, with no need for intraductal lithotripsy. A 10 Fr 12 cm transgastric plastic biliary stent was placed across the stenosis.
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The patient was discharged the day after the procedure and continued to do well 60 days later. This patient will need further stent replacement until a desirable and stable pancreaticojejunal opening is achieved.
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References
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- 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 Fujii LL, Topazian MD, Abu Dayyeh KB. et al. EUS-guided pancreatic duct intervention: outcomes of a single tertiary-care referral center experience. Gastrointest Endosc 2013; 78: 854-864.e1
- 4 Ryou M, Mullady DK, Dimaio CJ. et al. Pancreatic antegrade needle-knife (PANK) for treatment of symptomatic pancreatic duct obstruction in Whipple patients (with video). Gastrointest Endosc 2010; 72: 1081-1088
- 5 James TW, Baron TH. Antegrade pancreatoscopy via EUS-guided pancreaticogastrostomy allows removal of obstructive pancreatic duct stones. Endosc Int Open 2018; 6: E735-E738