Therapeutic endoscopy for stenotic pancreatodigestive tract anastomosis after pancreatoduodenectomy (with videos)

Abstract

Background: Pancreatodigestive tract anastomotic site stenosis is a problematic complication after pancreatoduodenectomy.

Objective: We evaluated the feasibility and efficacy of endoscopic treatments for a stenotic pancreatodigestive tract anastomosis.

Design: Retrospective study.

Setting: Endoscopic units of a university-affiliated hospital and a general hospital.

Patients: Fourteen patients with recurrent pancreatitis (n=10) and pancreatic fluid fistula (n=4) after anatomy-altering surgery with pancreatodigestive tract anastomosis.

Interventions: The initial ERCP included obtaining a pancreatogram, introducing a 0.025-inch guidewire through the anastomosis, along which a 5F plastic stent or nasopancreatic drain was inserted. If initial ERCP failed, we attempted EUS-guided rendezvous, with a guidewire passed antegrade from the main pancreatic duct across the stenotic anastomosis.

Main outcome measurements: Rates of successful intervention and clinical relief.

Results: The initial intervention was successfully achieved in 6 of 14 patients (38%). Of the 6 patients with successful therapeutic endoscopies, 4 (66.7%) and 2 (25.0%) had undergone a previous pancreatogastrostomy or pancreatojejunostomy, respectively. Eight patients with an initial unsuccessful intervention successfully underwent a second intervention using an EUS-guided or US-guided rendezvous method. Finally, stenosis was relieved in all patients with either the retrograde placement of a pancreatic duct stent across the stenosis of an anastomotic site or antegrade percutaneous bougienage of the stenotic anastomosis.

Limitations: Small sample size and lack of control patients.

Conclusions: Endoscopic treatment of stenotic pancreatodigestive tract anastomosis for transanastomotic pancreatic juice drainage is safe and feasible.