Endoscopic ultrasound-guided retrograde pancreatic stent placement for the treatment of stenotic jejunopancreatic anastomosis after a Whipple procedure
13 December 2013 (online)
Endoscopic ultrasound (EUS)-guided   or percutaneous  rendezvous methods have been used for the treatment of stenosis at the jejunopancreatic anastomosis following pancreatoduodenectomy. However, the use of EUS-guided retrograde pancreatic duct stenting has not been reported, even though it may be preferable from the point of view of complications.
A 50-year-old man, who had been suffering from repetitive pancreatitis for 1 year due to stenosis at the jejunopancreatic anastomosis after pancreatoduodenectomy ([Fig. 1 a]), underwent EUS-guided retrograde pancreatic duct stenting. Prior to the procedure, despite careful searching with a forward-viewing scope, the orifice of the pancreatic duct could not be detected due to severe luminal inflammation. A convex-type EUS scope (GF-UCT240; Olympus, Tokyo, Japan) was advanced to the anastomotic site ([Fig. 1 b]) and, using color Doppler, the puncture line was adjusted to avoid blood vessels. A 19-gauge needle (SonoTip Pro Control; Medi-globe, Achenmühle, Germany) was inserted into the main pancreatic duct ([Fig. 1 c]), and advancement of a guide wire (VisiGlide, 0.025-inch; Olympus) fully into the duct was confirmed using contrast medium ([Fig. 1 d]). Dilation was unsuccessful with a bougie catheter (Soehendra, 4 – 7 Fr; Cook Medical, Winston-Salem, North Carolina, USA), but was easily completed using a diathermic sheath (Cysto-Gastro Set, 6 Fr; Endo-Flex, Voerde, Germany) . A plastic stent (Geenen, 5 Fr; Cook Medical) was placed ([Fig. 1 e]) and the patient’s symptoms disappeared immediately.
Two months later, as scheduled, the stent was upsized to a 7 Fr with balloon dilation (Quantum TTC, 6 mm; Cook Medical) ([Fig. 2 a]). No complications occurred during these procedures and the patient was subsequently healthy ([Fig. 2 b]).
Compared with the rendezvous method, the retrograde procedure presented here is a one-step, one-scope method that is not performed through the abdominal cavity; hence, it carries a lower risk of pancreatic juice leakage and other complications . This method is worthwhile when attempting to rescue a stenotic pancreatojejunostomy after a Whipple resection.
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