Successful Endoscopic Treatment of Severe Pancreaticojejunostomy Strictures by Puncturing the Anastomotic Site with an EUS-guided Guidewire

Abstract

Pancreaticojejunostomy stricture (PJS) is a late complication of pancreaticoduodenectomy. The endoscopic treatment of PJS is very challenging due to the difficulty of locating the small anastomotic site and passing the stricture using a guidewire. We herein report two cases of severe PJS. These patients could not be treated using only double-balloon endoscopy or endoscopic ultrasound-guided puncture of the main pancreatic duct because of severe stenosis at the anastomotic site. However, we could treat them by the rendezvous technique using the rigid part of the guidewire to penetrate PJS. This method was useful and safe for treating severe PJS.

Keywords: endoscopic ultrasound; late complication; pancreaticoduodenectomy; pancreaticojejunostomy stricture; rendezvous technique.

Figure 1.

(a) CT revealed a pseudocyst in the pancreatic head (arrowhead) and the dilation of the main pancreatic duct (arrow). (b) Double-balloon endoscopy revealed a membranous pancreaticojejunostomy stricture. (c, d) CT demonstrated the dilation of the main pancreatic duct (arrow) and high-density fluid from the pancreatic tail to the perirenal cavity (circle).

Figure 2.

Pancreatic duct drainage using the rendezvous technique in case 1. (a) A 19-gauge needle was used to puncture the pancreatic duct. Pancreatography, with the injection of contrast medium through the 19-gauge needle revealed a dilated pancreatic duct. (b) A 0.025-inch guidewire and catheter were advanced but the guidewire and contrast medium did not reach the jejunum (arrow). (c) The rigid portion of the guidewire (arrowhead) was used to puncture the anastomotic site. (d) The guidewire and contrast medium confirmed the communication between the pancreatic duct and the jejunum. (e) After changing the EUS device to a double-balloon endoscope in order to perform the rendezvous technique, the anastomotic site was dilated using a balloon catheter (arrow). (f) A 5-Fr endoscopic nasopancreatic drainage catheter was placed into the main pancreatic duct through the anastomotic site.

Figure 3.

(a) CT revealed the dilation of the main pancreatic duct (arrow). (b) CT also revealed a pseudocyst in the pancreatic body (arrowhead) due to the leakage of pancreatic juice. (c) Double-balloon endoscopy showed the membranous pancreaticojejunostomy stricture (arrow).

Figure 4.

Pancreatic duct drainage using the rendezvous technique in case 2. (a) A 19-gauge needle was used to penetrate the pancreatic duct. Pancreatography with the injection of contrast medium through the 19-gauge needle revealed a dilated pancreatic duct. (b) A 0.025-inch guidewire and catheter were inserted, but the guidewire and contrast medium did not reach the jejunum (arrow). (c) The rigid portion of the guidewire (arrowhead) was punctured through the anastomotic site. (d) The passing of the guidewire and contrast medium confirmed the communication between the pancreatic duct and the jejunum. (e) After changing the EUS device to a double-balloon endoscope for the rendezvous technique, the anastomotic site was dilated using a balloon catheter (arrow). (f) A 5-Fr endoscopic nasopancreatic drainage catheter was placed into the main pancreatic duct through the anastomotic site.

Figure 5.

A schematic illustration of the approaches to PJS. (a) The Digestive tract procedure. (b) EUS-guided pancreatic duct puncture. (c) The rendezvous technique. (d) Pancreaticoenterostomy. (e) The rigid portion of the guidewire (circle) was able to pass through the severe PJS.