Endoscopic biliary access after pancreaticoduodenectomy following Imanaga’s procedure

Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice to drain the main biliary duct with a high degree of technical success [1]. However, in the case of a pancreaticoduodenectomy, endoscopic biliary access can be challenging. Imanaga’s procedure is a pylorus-preserving pancreaticoduodenectomy procedure with the duodenojejunal, pancreaticojejunal, and hepaticojejunal anastomosis reconstructed in that order on the jejunal limb ([Fig. 1]) [2] [3]. This procedure is thought to allow easier endoscopic access to the hepaticojejunal anastomosis [4].

Fig. 1 a Schematic representation of the Imanaga’s montage. b Surgical view with the duodenojejunal anastomosis (green asterisk), the pancreaticojejunal anastomosis (blue asterisk), and the choledochojejunal anastomosis (black asterisk).

Here we report two cases of endoscopic biliary access after Imanaga’s procedure. ([Video 1]). The first case is a 70-year-old man who underwent Imanaga’s procedure 4 months before for a duodenal lesion that could not be resected endoscopically. He subsequently had cholestasis with a stenosis of the biliary anastomosis. The anastomosis was hard to find with a duodenoscope, but thanks to immersion, the anastomosis was retrieved and cannulated with deployment of a self-expandable metal stent to calibrate the anastomosis ([Fig. 2]).

Video 1 Endoscopic biliary access after pancreaticoduodenectomy following Imanaga’s procedure.

Fig. 2 Self-expandable metal stent deployed at the choledochojejunal anastomosis.

The second case is a 70-year-old man who underwent Imanaga’s procedure 1 month before for an intraductal papillary mucinous neoplasm. A stenosis of the biliary anastomosis occurred with cholestasis and one episode of cholangitis. Endoscopic management of the stenosis was decided. Despite intensive searching, the biliary anastomosis was not found. An echoendoscope was used to visualize the common bile duct with a dilation of 7 mm and a clear stop. With a 19G needle, the biliary duct was punctured and opacified, and a guidewire was then positioned. To recalibrate the biliary anastomosis, a lumen-apposing metal stent was deployed, allowing satisfying biliary drainage ([Fig. 3]). Neither patient experienced any adverse event, and their cholestasis improved in the following days.

Fig. 3 Deployment of a lumen-apposing metal stent at the choledochojejunal anastomosis.

This e-video illustrates two successful endoscopic biliary accesses in patients with a history of pylorus-preserving pancreaticoduodenectomy following Imanaga’s procedure without the need of double-balloon endoscopy.

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• References

• 1 Balik E, Eren T, Keskin M. et al. Parameters that may be used for predicting failure during endoscopic retrograde cholangiopancreatography. J Oncol 2013; 2013: 201681
• 2 Imanaga H. A new method of pancreaticoduodenectomy designed to preserve liver and pancreatic function. Surgery 1960; 47: 577-586
• 3 Kimura Y, Yasukawa D, Aisu Y. et al. Imanaga’s first method for reconstruction with preservation of mesojejunal autonomic nerves during pylorus-preserving pancreatoduodenectomy. Am J Case Rep 2018; 19: 608-613
• 4 Krige JE, Nicol AJ, Navsaria PH. Emergency pancreatoduodenectomy for complex injuries of the pancreas and duodenum. HPB 2014; 16: 1043-1049