Endoscopic ultrasound-guided pancreaticogastrostomy reconstruction

Severe stenosis and obstruction of a pancreaticogastrostomy anastomosis sometimes occurs after surgical pancreatic resection and pancreaticogastrostomy, resulting in abdominal pain and aggravation of diabetes as a result of ductal hypertension [1]. Endoscopic ultrasound-(EUS-)guided pancreaticogastrostomy has been reported as a method for reducing ductal hypertension in patients with chronic pancreatitis. We report a patient who underwent EUS-guided reconstruction of a pancreaticogastrostomy with gastropancreatic stent placement, which rapidly improved his symptoms [2] [3].

A 65-year-old man who had a branch duct type of intrapapillary mucinous neoplasm (IPMN) ([Figure 1]) underwent a duodenum-preserving pancreatic head resection and pancreaticogastrostomy anastomosis. Forty-five days later, he developed a pancreatic pseudocyst ([Figure 2]), which was drained under EUS guidance. Although computed tomography 6 months later showed that the pseudocyst had disappeared, the scan showed dilatation of the main pancreatic duct ([Figure 3]). Decompression of the pancreatic duct was required to relieve his abdominal pain and reduce his hyperglycemia. Because the main pancreatic duct could not be drained by endoscopic retrograde pancreatography, EUS-guided pancreaticogastrostomy reconstruction was performed. An echo endoscope (GF-UC240 P-AL5; Olympus, Tokyo, Japan) was introduced into the stomach, and a 19-gauge needle (Echo-Tip; Wilson-Cook, Winston-Salem, North Carolina, USA) was used to puncture the main pancreatic duct and create a gastropancreatic fistula. We initially attempted to pass a 0.035-inch guide wire (Microvasive Endoscopy, Boston Scientific Corporation, Natick, Massachusetts, USA) through the stenotic anastomosis, but the guide wire could not be passed through the anastomosis ([Figure 4]). A 6-Fr (Soehendra Biliary Dilation Catheters, Wilson-Cook, Winston-Salem, North Carolina, USA) dilator was advanced over the guide wire to dilate the gastropancreatic fistula, and then a 5-Fr, 5-cm-long pancreatic stent (Geenen Pancreatic Stent Set, Wilson-Cook, Winston-Salem, North Carolina, USA) was advanced over the wire and through the gastropancreatic fistula. The stent was placed in the pancreatic duct with the tip positioned in the proximal duct ([Figure 5], [Figure 6]). The patient’s abdominal pain was rapidly relieved and his hyperglycemia had improved 1 month later.

Figure 1 Magnetic resonance cholangiopancreatographic view showing the dilated branch of the pancreatic duct and a mural nodule in the dilated duct (arrow).

Figure 2 Computed tomographic view showing a pancreatic pseudocyst that developed 3 months after the surgical resection and pancreaticogastrostomy.

Figure 3 Computed tomographic view, showing the dilated main pancreatic duct 6 months after drainage of the pancreatic pseudocyst.

Figure 4 Fluoroscopic image showing a guide wire in the dilated duct, complete obstruction of proximal duct, outflow of the contrast through the cystogastrostomy stent, and placement of a guide wire into the distal pancreatic duct. The arrows show the previous drainage stent of the pancreatic pseudocyst.

Figure 5 Endoscopic view of the stent inserted into the pancreatic duct.

Figure 6 Fluoroscopic image showing placement of the stent through the gastropancreatic fistula (arrows). The tip of the stent was positioned in the proximal duct.

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References

• 1 Amano H, Takada T, Ammori B J. et al . Pancreatic duct patency after pancreaticogastrostomy: long-term follow-up study.  Hepatogastroenterology. 1998;  45 2382-2387
• 2 Francois E, Kahalen M, Giovannini M. et al . EUS-guided pancreaticogastrostomy.  Gastrointest Endosc. 2002;  56 128-133
• 3 Gress F, Ikenberry S, Sherman S. et al . Endoscopic ultrasound-directed pancreatography.  Gastrointest Endosc. 1996;  44 736-739