Endoscopic pancreatic stenting using the combination technique of injection needle and needle knife for complete pancreaticojejunal anastomotic obstruction.

Abstract

Watch a video of this article. A 69-year-old woman who underwent pancreaticoduodenectomy presented with chronic diarrhea and exacerbation of diabetes mellitus. Magnetic resonance cholangiopancreatography revealed dilatation of the main pancreatic duct (MPD) (Fig. 1a). Exocrine and endocrine pancreatic insufficiency due to pancreaticojejunal anastomotic stenosis (PJS) were considered as possible causes of the symptoms. Therefore, endoscopic retrograde pancreatography (ERP) was planned. On endoscope (PCF-H290ZI; Olympus Medical Systems, Tokyo, Japan) insertion, the anastomotic site (AS), which was characterized by membranous obstruction, was identified (Fig. 2a). ERP using a conventional cannulation method was considered difficult because of complete anastomotic obstruction (CAO). As we confirmed that there were no major blood vessels around the AS on computed tomography (Fig. 1b), ERP using an injection needle (23-G TOP endoscopic injection needle; TOP, Tokyo, Japan) was performed. Four punctures were required for ERP and dilatation of the MPD was observed (Fig. 2b). The AS was incised using a needle knife (KD-1L-1; Olympus Medical Systems) (Fig. 2c). After incision of the AS and guidewire placement, it was dilated using a dilator (ES dilator; Zeon Medical, Tokyo, Japan) and a 5-Fr × 5-cm pancreatic stent (Advanix Pancreatic Stent; Boston Scientific Japan, Tokyo, Japan) was placed without adverse events (Fig. 2d) (Video S1). For CAO in PJS, endoscopic ultrasound-guided pancreatic duct drainage is preferred because endoscopic pancreatic stenting under ERP (EPS) is technically challenging.1-3 However, EPS has the advantage that it can be safely performed using a physiological route.4 Similar to our technique, for CAO in hepaticojejunostomy, cholangiography and guidewire placement were simultaneously performed through a 20-G injection needle, and the access route to the bile duct was secured using a diathermic dilator via a guidewire.5 This technique should also be considered because it does not involve a blind incision with the risk of perforation. EPS using these techniques may be a treatment option for CAO. This study was conducted in accordance with the ethical standards described in the latest revision of the Declaration of Helsinki. Informed consent for patient participation and publication was received. All data relevant to the study are included in the article. Authors declare no conflict of interest for this article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.