Gastrointestinal: Antegrade metal stent deployment for pancreaticojejunostomy stricture under endoscopic ultrasound guidance.

Abstract

The frequency of pancreaticojejunostomy stricture (PJS) arising after pancreatoduodenostomy ranges from 2% to 11%. This adverse event can lead to obstructive pancreatitis including pancreatic stone formation and thus requires treatment. Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has recently been developed as an alternative to failed endoscopic retrograde cholangio-pancreatography. We herein describe technical tips for advanced EUS-PD, including antegrade endoscopic hydraulic lithotripsy of pancreatic stones and antegrade electrocautery dilation with metal stent deployment to treat the PJS. A 59-year-old man was referred to us due to frequent pancreatitis. He had undergone pancreatoduodenostomy 2 years previously to treat bile duct cancer, which did not recur during clinical follow-up at our hospital. However, he experienced frequent pancreatitis within 6 months. Computed tomography revealed PJS with pancreatic duct stones. Therefore, EUS-PD was attempted, initially using a plastic stent, which was removed after 1 week. A SPY-DS pancreatoscope (Boston Scientific, Tokyo, Japan) inserted into the pancreatic duct through the EUS-PD route over a VisiGlide 1 guidewire (Olympus Medical Systems, Tokyo, Japan) revealed stones in the pancreatic duct. These were fragmented using endoscopic hydraulic lithotripsy (Fig. 1a), and then a PJS was visualized and confirmed as benign. Thus, the PJS was dilated using antegrade with a Fine 025 dilator (Medico's Hirata Inc., Osaka Japan) (Fig. 1b), and pancreatography subsequently confirmed the dilated PJS (Fig. 1c). An antegrade covered metal BONASTENT M-Intraductal stent (Standard Sci-Tech Inc., Seoul, South Korea) and plastic stent were deployed at the PJS site (Figs 1d and 1e) without any adverse events (Video). After 1 month, stricture was resolved, and this patient underwent clinical follow-up without recurrence of PJS. This technique might be clinically useful to treat PJS, although it awaits evaluation by a prospective comparative study. Video S1. A catheter and guidewire for ERCP are inserted into the main pancreatic duct through fistula, and contrast medium is injected, revealing a pancreatic duct stone. Pancreatoscope is antegradely inserted through the fistula, and endoscopic hydraulic lithotripsy proceeds to fragment the pancreatic stone. The site of a pancreaticojejunostomy stricture is identified and dilated using antegrade electrocautery, followed by antegrade stent deployment. Finally, a plastic stent is deployed from main the pancreatic duct to the stomach. 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.