Encoscopic Management of Stenotic Anastomosis Using a Rendezvous Technique After Pancreatogastrostomy

Abstract

A 46-year-old female patient was referred to our hospital for endoscopic treatment of stenotic pancreatogastrostomy. She had undergone pylorus-preserving pancreatoduodenectomy due to duodenal carcinoma of the papilla of Vater 5 years before referral. Two years after the operation, she had to be hospitalized several times during a 1-year period because of acute recurrent pancreatitis caused by stenosis of the anastomosis of the pancreatoduodenostomy. An endoscopic ultrasound (EUS)-guided rendezvous technique was selected to puncture the main pancreatic duct via a transgastric approach. We identified the dilated main pancreatic duct with a convex array echoendoscope from the lower gastric body near the anastomosis and successfully punctured the dilated main pancreatic duct. The guidewire passed through the stenosis to the gastric cavity and we could place a stent through the stenotic anastomosis. After the procedure, the patient has not experienced acute recurrent pancreatitis for 9 months. Pancreatogastrostomy has been the preferred method used to carry out post-pancreatoduodenectomy reconstruction. However, stenosis of the anastomosis has been reported as one of the late complications of pancreatogastrostomy. The main symptom of this complication is recurrent epigastralgia due to obstructive pancreatitis. As a result, patients are compelled to stay in the hospital for an extended duration with no oral intake allowed. Surgical resection of the stenosis is often the treatment of choice but can be troublesome due to post-operative adhesions. Here, we report a case of pancreatogastrostomy complicated by stenosis, which was treated using the EUS-guided rendezvous technique.

Percutaneous Pancreatic‐duct Puncture With Rendezvous Technique Can Treat Stenotic Pancreaticojejunostomy

“…Previously, we reported the successful endoscopic treatment of stenotic pancreaticogastrostomy by performing incision with a needle knife 3–5 . In the present case, we tried to dilate the stenotic anastomosis using the same procedure, but failed because the anastomosis could not be visualized, which is similar to the experience of Mallery et al 8 .…”

“…Stenotic pancreatico‐enteric anastomosis is one of the serious late complications after a pancreaticoduodenectomy (PD) and causes recurrent obstructive pancreatitis, 1 sometimes necessitating a second operation 2 . Previously, we have reported cases of stenotic pancreaticogastrostomy successfully treated using endoscopic procedures to perform incision of a stenotic anastomosis with a rendezvous method 3–5 …”

“…2 Previously, we have reported cases of stenotic pancreaticogastrostomy successfully treated using endoscopic procedures to perform incision of a stenotic anastomosis with a rendezvous method. [3][4][5] Here, we report a case of stenotic pancreaticojejunostomy with a pancreatic juice fistula drained externally, which was treated using percutaneous procedures combined with a rendezvous method.…”

Strategy to Treat Pancreatic Fistula Using Comprehensive Endoscopic Procedures Together with Percutaneous Methods

“…When these treatments had been performed, a EUS endoscope for puncture had not been introduced to our hospital and the treatment for a strictured anastomosis using EUS had been scarcely reported. However, now, these treatments could be accomplished using a EUS endoscope for puncture in patients with pancreatogastrostomy [17], and also in patients with pancreatojejunostomy, if the endoscope could be introduced into the anastomotic site [11]. Moreover, the percutaneous method used to treat PF in Case 5 can also be treated using a EUS endoscope for puncture, if the endoscope can be introduced into the anastomotic site.…”

Pancreatic antegrade needle-knife (PANK) for treatment of symptomatic pancreatic duct obstruction in Whipple patients (with video)

“…[12][13][14][15][16] These techniques also use EUS-guided transgastric or transbulbar puncture of the MPD followed by placement of 1 or 2 transgastric or transbulbar stents for retrograde MPD drainage. A second procedure is required 8 weeks later for stent replacement.…”