Endoscopy 2013; 45(S 02): E435-E436
DOI: 10.1055/s-0033-1358923
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic ultrasound-guided retrograde pancreatic stent placement for the treatment of stenotic jejunopancreatic anastomosis after a Whipple procedure

Hiroyuki Matsubayashi
1  Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
,
Yoshihiro Kishida
1  Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
,
Kunihiro Shinjo
1  Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
,
Kenichiro Imai
1  Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
,
Kinichi Hotta
1  Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
,
Masaki Tanaka
1  Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
,
Naomi Kakushima
1  Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
,
Kohei Takizawa
1  Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
,
Takashi Mizuno
2  Department of Hepatopancreaticobiliary Surgery, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
,
Yukiyasu Okamura
2  Department of Hepatopancreaticobiliary Surgery, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
,
Hiroyuki Ono
1  Division of Endoscopy, Shizuoka Cancer Center, Suntogun, Shizuoka, Japan
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Publikationsverlauf

Publikationsdatum:
13. Dezember 2013 (online)

Endoscopic ultrasound (EUS)-guided [1] [2] or percutaneous [3] 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) [4]. A plastic stent (Geenen, 5 Fr; Cook Medical) was placed ([Fig. 1 e]) and the patient’s symptoms disappeared immediately.

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Fig. 1 a – e Images of the pancreatitis and the initial procedure: a computed tomography (CT) showing a dilated main pancreatic duct (MPD), fluid collection at the anastomosis (arrowhead), and a thickened jejunal wall (arrows); b scope placed at the anastomosis; c color Doppler image showing the needle striking into the duct (arrow); d plaques visible in the MPD (arrows); e a pancreatic stent placed through the jejunum.
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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]).

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Fig. 2 a, b The second procedure and following CT: a balloon dilation of the stenotic jejunopancreatic anastomosis for upsizing of the stent; b CT view showing healing of the jejunal and peripancreatic inflammation and the pancreatic stent in place in the nondilated MPD.
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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 [5]. This method is worthwhile when attempting to rescue a stenotic pancreatojejunostomy after a Whipple resection.

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