Pancreatoenteric anastomotic site stenosis can be a problematic complication after PD. Reid-Lombardo et al. reported that stenotic pancreaticojejunostomy requiring intervention was observed in 4.6% of PD patients[2
]. The Patients with stenotic pancreaticojejunostomy after PD tended to be treated with ERCP-related procedures. However, the success rates were not often high due to the inability to reach or to identify the pancreaticojejunostomy through the afferent loop[3
]. A long afferent loop and postoperative adhesions might hamper endoscopic treatment. Whether lateral-viewing, forward-viewing or oblique-viewing endoscope was chosen, it has been unclear which type is the appropriate choice. Kikuyama et al[4
] suggested that oblique-viewing endoscope was a good option for ERCP in operated patients, since it was useful for deep cannulation and therapeutic procedures due to the instrument elevator and good angle of view for advancing into the afferent loop. If a conventional endoscope was unable to reach the pancreaticojejunostomy, single or double balloon enteroscopes should be used as an alternative[5
]. However, these endoscopes were not appropriate for interventional endoscopic treatment due to the small forceps’ channel. In our case, we performed ERCP using an oblique-viewing endoscope and we could reach and identify the pancreaticojejunostomy because the afferent loop was not long (Figure ). However, pancreatography and guidewire insertion into the pancreatic duct were not possible.
Recently, interventional EUS has greatly advanced in terms of available devices and techniques. Bataille et al[6
] first reported pancreatic duct drainage with EUS-guided rendezvous technique in 2002. Thereafter, several reports have described this procedure in post-PD patients (Table )[4,7-11
]. This procedure is technically challenging and has an approximately 50% success rate. The reasons for failure include the impossibility of puncturing the pancreatic duct without dilatation, and the inability to pass through the stenotic anastomosis due to its tightness and less than ideal orientation of the puncture. Although the early course of this patient was favorable, it is important to follow up this patient carefully due to the risk of restenosis of pancreaticojejunostomy.
Reported cases of pancreatic duct drainage using endoscopic ultrasonography-guided rendezvous technique for stenosis of after pancreticojejunostomy
Kikuyama et al[4
] have described difficulty in passing the stenotic anastomosis due to a tight stenosis, since stenosis of the pancreaticoenteric anastomosis usually happens as a late complication[2
]. In our case, we expected that the stenosis was not tight since the stenosis developed about a month after PD due to a pancreatic fistula and an intra-abdominal abscess. We supposed that the length of time after the operation and the severity of other complications such as a pancreatic fistula might affect the outcomes, in terms of fibrosis, edema and compression occupying the space around the anastomotic site.
The diameter of the pancreatic duct is an important factor in avoiding complications as well as success. We could achieve successful pancreatic duct drainage in this case since the MPD was dilated enough to puncture (6 mm). Fatal complications have never been reported with this procedure, while a few complications such as abscess, mild pancreatitis or transient fever were reported, and these complications mostly happened to patients with pancreatic ducts of normal diameter[7,9
]. Accordingly, for the EUS-guided rendezvous techniques we should select patients who satisfy these conditions.
EUS-guided pancreaticogastrostomy was an option for the treatment of this case. EUS-guided pancreaticogastrostomy has the risk of stent dysfunctions such as obstruction and migration[12
], whereas dilatation of the stenotic anastomosis by a balloon catheter has a small risk of restenosis[4
]. We therefore selected balloon dilatation for stenotic pancreaticojejunostomy using the rendezvous technique. Our case suggests that stenotic pancreaticojejunostomy ocurring at any early stage after PD with a dilated pancreatic duct might be a good indication for this technique.