Gastro-pancreaticojejunostomy for treatment of pancreatic ductal obstruction in a post-Whipple procedure patient

Abstract

We report a case of a woman with a medical history of classic Whipple surgery who underwent endoscopic ultrasound (EUS)-guided pancreatic drainage due to smouldering acute pancreatitis secondary to an obstructing pancreatic ductal stone. A gastro-pancreaticojejunostomy anastomosis was created anterogradely, with dilation of both the anastomoses in the same procedure, with subsequent decompression of the pancreatic duct. Endoscopic retrograde pancreatography (ERP) is often impossible to perform in patients with post-Whipple procedure anatomy due to inaccessibility to the pancreaticojejunostomy anastomosis. EUS-guided pancreatic drainage may be offered in these patients in whom the pancreatic duct cannot be accessed at ERP. It has been used as a platform for access to and drainage of the pancreatic duct either by rendezvous or transmural drainage. However, only one of four patients achieve successful completion of the rendezvous procedure. There are limited data regarding safety and long-term outcome of this procedure, as well as scant guidelines on the optimal time for leaving stents in place. We believe definitive endoscopic therapy should be attempted, whenever possible, after relief of obstruction. In our case, we expect that stent occlusion is inevitable and that long-term drainage is possible due to drainage occurring between the stent and the stone.

Longitudinal Pancreaticojejunostomy for Pancreaticodigestive Tract Anastomotic Stricture After Pancreaticoduodenectomy

“…Endoscopic intervention, which is less invasive than surgical intervention, may be another treatment of choice. Several reports have described EUS‐guided PG with pancreatic duct stenting in pancreaticodigestive tract anastomotic stricture after PD 18‐21 . However, this procedure is technically challenging and has a success rate of only ~50% 18 .…”

“…Several reports have described EUS‐guided PG with pancreatic duct stenting in pancreaticodigestive tract anastomotic stricture after PD. 18 , 19 , 20 , 21 However, this procedure is technically challenging and has a success rate of only ~50%. 18 Moreover, its long‐term efficacy has not yet been reported.…”