Microcatheter-assisted guidewire manipulation via peroral pancreatoscopy for recanalization of pancreaticojejunostomy obstruction

Pancreatojejunostomy stricture is one of the complications after pancreaticoduodenectomy [1]. Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has emerged as an alternative to enteroscopy-guided treatment. We present a case demonstrating the successful coordinated manipulation of a 3-Fr microcatheter and pancreatoscopy for recanalization of a complete pancreaticojejunostomy obstruction.

A 72-year-old man, who had previously undergone pancreaticoduodenectomy for distal bile duct cancer, presented with pancreatitis due to a pancreaticojejunostomy anastomotic stricture ([Fig. 1] a). As the anastomosis could not be identified by the enteroscopy-guided approach, EUS-PD was performed. The anastomosis was completely stenosed on contrast imaging and an attempt to negotiate the obstruction using a guidewire under fluoroscopic guidance failed; therefore, a plastic stent was deployed in the main pancreatic duct ([Fig. 1] b).

Fig. 1 Initial imaging. a Computed tomography scan showed dilation of the main pancreatic duct. b Attempts to advance the guidewire through the obstruction were unsuccessful.

Another attempt to advance the guidewire through the anastomotic obstruction was unsuccessful 3 months after EUS-PD. A covered metal stent (Hanaro Benefit; Boston Scientific, Marlborough, Massachusetts, USA) was placed over the fistula of the pancreaticogastrostomy. Then, 1 week later, the SpyGlass DS digital single-operator cholangioscope (Boston Scientific) was inserted into the pancreatic duct via the metal stent. However, the obstruction could still not be breached with guidewire manipulation under peroral pancreatoscopy. A 3-Fr microcatheter (Daimon-ERCP-catheter; Hanaco Medical, Saitama, Japan) was then introduced through the pancreatoscope, and guidewire manipulation under the microcatheter enhanced maneuverability, facilitating breakthrough and enabling successful penetration of the anastomotic site ([Fig. 2]). After confirming the jejunum using contrast injection through the microcatheter, a plastic stent was successfully placed transgastrically to bridge the pancreatic duct and jejunal anastomosis in an antegrade fashion ([Video 1]).

Fig. 2 Successful guidewire placement. a Coordinated manipulation of the guidewire and a 3-Fr microcatheter (Daimon-ERCP-catheter; Hanaco Medical, Saitama, Japan) under the SpyGlass DS digital single-operator cholangioscope (Boston Scientific, Marlborough, Massachusetts, USA) allowed successful penetration of the anastomotic site. b Confirmation of the jejunum using contrast injection through the microcatheter. c The peroral pancreatoscopy image showed the guidewire penetrating the anastomotic site.

3-Fr microcatheter-assisted peroral pancreatoscopy via pancreaticogastrostomy for recanalization of pancreaticojejunostomy obstruction.Video 1

Peroral pancreatoscopy through the pancreaticogastrostomy fistula has been reported as an effective and safe option for antegrade guidewire placement [2], but challenges persist, particularly when navigating the guidewire through the pancreatoscope. The microcatheter offers distinct advantages, including the ability to obtain selective contrast-enhanced images and enhanced maneuverability of the guidewire for a super-selective approach [3].

Endoscopy_UCTN_Code_TTT_1AS_2AD

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Cioffi JL, McDuffie LA, Roch AM. et al. Pancreaticojejunostomy stricture after pancreatoduodenectomy: outcomes after operative revision. J Gastrointest Surg 2016; 20: 293-299
• 2 Suzuki A, Ishii S, Fujisawa T. et al. Efficacy and safety of peroral pancreatoscopy through the fistula created by endoscopic ultrasound-guided pancreaticogastrostomy. Pancreas 2022; 51: 228-233
• 3 Yoshida M, Naitoh I, Hayashi K. et al. Various innovative roles for 3-Fr microcatheters in pancreaticobiliary endoscopy. Dig Endosc 2022; 34: 632-640

Publication History

Article published online:
20 March 2025