Endoscopic ultrasound-guided retrograde pancreatic stent placement for the treatment of stenotic jejunopancreatic anastomosis after a Whipple procedure.

Endoscopic ultrasound (EUS)-guided [1, 2] or percutaneous [3] rendezvous methods have been used for the treatment of stenosis at the jejunopancreatic anastomosis following pancreatoduodenectomy. However, the use of EUS-guided retrograde pancreatic duct stenting has not been reported, even though it may be preferable from the point of view of complications. A 50-year-old man, who had been suffering from repetitive pancreatitis for 1 year due to stenosis at the jejunopancreatic anastomosis after pancreatoduodenectomy (●" Fig.1a), underwent EUS-guided retrograde pancreatic duct stenting. Prior to the procedure, despite careful searching with a forward-viewing scope, the orifice of the pancreatic duct could not be detected due to severe luminal inflammation. A convex-type EUS scope (GFUCT240; Olympus, Tokyo, Japan) was advanced to the anastomotic site (●" Fig.1b) and, using color Doppler, the puncture line was adjusted to avoid blood vessels. A 19-gauge needle (SonoTip Pro Control; Medi-globe, Achenmühle, Germany) was inserted into the main pancreatic duct (●" Fig.1c), and advancement of a guide wire (VisiGlide, 0.025-inch; Olympus) fully into the duct was confirmed using contrast medium (●" Fig.1d). Dilation was unsuccessful with a bougie catheter (Soehendra, 4–7Fr; Cook Medical, Winston-Salem, North Carolina, USA), but was easily completed using a diathermic sheath (Cysto-Gastro Set, 6Fr; Endo-Flex, Voerde, Germany) [4]. A plastic stent (Geenen, 5Fr; Cook Medical) was placed (●" Fig.1e) and the patient’s symptoms disappeared immediately. Two months later, as scheduled, the stent was upsized to a 7Fr with balloon dilation (Quantum TTC, 6mm; Cook Medical) (●" Fig.2a). No complications occurred during these procedures and the patient was subsequently healthy (●" Fig.2b). Compared with the rendezvous method, the retrograde procedure presented here is a one-step, one-scope method that is Fig.1 a–e Images of the pancreatitis and the initial procedure: a computed tomography (CT) showing a dilated main pancreatic duct (MPD), fluid collection at the anastomosis (arrowhead), and a thickened jejunal wall (arrows); b scope placed at the anastomosis; c color Doppler image showing the needle striking into the duct (arrow); d plaques visible in the MPD (arrows); e a pancreatic stent placed through the jejunum. Cases and Techniques Library (CTL) E435