Safety and efficacy of trans-afferent loop endoscopic ultrasound-guided pancreaticojejunostomy for post pancreaticoduodenectomy anastomotic stricture using the forward-viewing echoendoscope: a retrospective study from Japan

Abstract

Background/aims: Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is a well-established procedure for managing pancreaticojejunostomy anastomotic strictures (PJAS) post-Whipple surgery. In this study, we examined the effectiveness and safety of EUS-guided pancreaticojejunostomy (EUS-PJS).

Methods: This retrospective, single-arm study was performed at Aichi Cancer Center Hospital on 10 patients who underwent EUS-guided pancreaticojejunostomy through the afferent jejunal loop using a forward-viewing echoendoscope when endoscopic retrograde pancreatography failed. Our primary endpoint was technical success rate, defined as successful stent insertion. The secondary endpoints were early and late adverse events.

Results: A total of 10 patients underwent EUS-PJS between February 2019 and October 2023. The technical success rate was 100%. The median procedure time was 23.5 minutes. No remarkable early or late adverse events related to the procedure, except for fever, occurred in two patients. The median follow-up duration was 9.5 months, and the median number of stent exchanges was two. A stent-free state was achieved in three patients.

Conclusions: EUS-PJS for PJAS management after pancreaticoduodenectomy appears to be an effective and safe procedure with the potential advantages of fewer reinterventions and the creation of a permanent drainage fistula.

Keywords: Drainage; Endosonography; Gastrointestinal endoscopy; Pancreatic ducts; Pancreaticoduodenectomy.

Fig. 1.

Flowchart of our pancreaticojejunostomy anastomotic stricture management policy. ERP, endoscopic retrograde pancreatography; EUS, endoscopic ultrasound; EUS-PGS, EUS-guided pancreaticogastrostomy; EUS-PJS, EUS-guided pancreaticojejunostomy.

Fig. 2.

Endoscopic ultrasound-guided pancreaticojejunostomy procedure steps. (A) A colonoscope inserted into the afferent jejunal limb till the pancreaticojejunal anastomosis. (B) After endoscopic retrograde pancreatography failure, a guidewire is left in the jejunum, and the scope is exchanged. (C) A forward-viewing echoendoscope is inserted over the guidewire until anastomosis is achieved. (D) The pancreatic duct is punctured using a fine needle aspiration needle, and a guidewire is inserted. (E) Tract dilation using Tornus ES drill dilator. (F) Finally, a fully covered self-expandable metal stent is deployed inside the pancreatic duct across the anastomosis.

Fig. 3.

Endoscopic ultrasound image showing the anastomosis line. MPD, main pancreatic duct.

Fig. 4.

Making artificial openings in the fully covered self-expandable metal stent. First, we deployed 1 to 2 cm of the stent outside the patient, made multiple openings in the stent cover using a simple needle or the sharp tip of a fine needle biopsy needle, and finally recaptured the stent.

Fig. 5.

Endoscopic view of a widely open pancreaticojejunal anastomosis after stent removal in the endoscopic ultrasound-guided pancreaticojejunostomy (EUS-PJS)

Fig. 6.

Puncture tract in endoscopic ultrasound-guided pancreaticogastrostomy (EUS-PGS) and EUS-guided pancreaticojejunostomy (EUS-PJS). (A) The puncture tract in EUS-PGS, where the fistula is created through the pancreatic parenchyma. (B) Puncture tract in EUS-PJS, where the fistula is created through the anastomosis and not the parenchyma, using a forward-viewing scope.