Recanalization of an obstructive pancreaticojejunal anastomosis with direct visualization by using antegrade peroral pancreatoscopy

A 60-year-old man came to our hospital complaining of upper abdominal pain possibly due to stenosis of a pancreaticojejunal anastomosis with upstream dilation of the main pancreatic duct ([Fig. 1]). Because an endoscopic transluminal approach via the afferent loop failed, we performed endoscopic ultrasound (EUS)-guided pancreatic drainage with a 19-gauge needle (EZ Shot 3 Plus; Olympus Co., Tokyo, Japan). However, no contrast medium flowed out of the dilated main pancreatic duct to the jejunum ([Fig. 2]), and a 0.025-inch guidewire could not be inserted across the anastomosis. A 7-Fr plastic stent was exchanged, 1 month later, for a 6-mm fully covered self-expandable metallic stent (Niti-S Biliary S-type Stent, Century Medical Co., Ltd., Tokyo, Japan) across the pancreaticogastrostomy to perform peroral pancreatoscopy (POPS) ([Fig. 3]). A SpyGlass DS system (Boston Scientific Co., Marlborough, Massachusetts, USA) was used to perform POPS to visualize the anastomosis from the inside of the main pancreatic duct ([Video 1]). We found the duct completely obstructed at the anastomotic site and covered with fibrotic tissues ([Fig. 4]). It was difficult to break through this obstruction even with POPS guidance. However, repeated poking with a guidewire partially broke the fibrotic tissues and a guidewire could finally be passed through the anastomosis. After dilation of this anastomosis using a 7-Fr catheter and a 6-mm balloon catheter, contrast medium immediately flowed from the main pancreatic duct to the jejunum. No procedure-related adverse events were observed, and the abdominal symptoms improved after treatment.

Fig. 1 Contrast-enhanced computed tomography (coronal views) showing the dilated main pancreatic duct of the remnant pancreas (arrow).

Fig. 2 Endoscopic ultrasound-guided pancreatic drainage. a The dilated main pancreatic duct (arrow) was punctured with a 19-gauge needle under endoscopic ultrasound guidance. b From fluoroscopy, no contrast medium flowed out of the dilated pancreatic duct (arrowhead).

Fig. 3 A 6-mm fully covered self-expandable metallic stent was inserted across the pancreaticogastrostomy.

Video 1 Recanalization of the stenosis of a pancreaticojejunal anastomosis under direct visualization by using antegrade peroral pancreatoscopy via endoscopic ultrasound-guided pancreaticogastrostomy.

Fig. 4 Peroral pancreatoscopy (POPS) using a SpyGlass DS system. a POPS revealed complete obstruction of the main pancreatic duct at the anastomotic site, which was covered with fibrotic tissues. b The fibrotic tissues were partially broken by poking repeatedly with a guidewire. c A guidewire could be passed through the anastomosis. d After the anastomosis was dilated by use of a dilator and balloon catheter along the guidewire, POPS images confirmed that the anastomosis site was adequately dilated.

Although the efficacy of EUS-guided pancreatic drainage for stenosis of the pancreaticojejunal anastomosis has been described [1] [2], the procedure is still challenging. Recently, the usefulness of cholangioscopy for stenosis of the bilioenteric anastomosis has been reported [3] [4]. Therefore, direct visualization using POPS via EUS-guided pancreaticogastrostomy appears to be a promising alternative method if fluoroscopic interventions have failed.

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Competing interests

The authors declare they have no conflict of interest.

• References

• 1 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
• 2 Ogura T, Nishioka N, Yamada M. et al. Two-step endoscopic ultrasound-guided rendezvous technique combined with antegrade electrohydraulic lithotripsy for a huge pancreatic duct stone. Endoscopy 2019; 51: E149-E150
• 3 Fujii Y, Koshita S, Ito K. Percutaneous transhepatic cholangioscopy using SpyGlassDS for an anastomotic stenosis after choledochojejunostomy. Dig Endosc 2018; 30: 806-807
• 4 Hakuta R, Kogure H, Nakai Y. et al. Successful guidewire placement across hilar biliary stricture after decreased donor liver transplantation using new digital cholangioscopy. Endoscopy 2018; 50: E54-E56

Publication History

Article published online:
27 March 2020