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

BackgroundPancreatodigestive tract anastomotic site stenosis is a problematic complication after pancreatoduodenectomy.ObjectiveWe evaluated the feasibility and efficacy of endoscopic treatments for a stenotic pancreatodigestive tract anastomosis.DesignRetrospective study.SettingEndoscopic units of a university-affiliated hospital and a general hospital.PatientsFourteen patients with recurrent pancreatitis (n = 10) and pancreatic fluid fistula (n = 4) after anatomy-altering surgery with pancreatodigestive tract anastomosis.InterventionsThe 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 MeasurementsRates of successful intervention and clinical relief.ResultsThe 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.LimitationsSmall sample size and lack of control patients.ConclusionsEndoscopic treatment of stenotic pancreatodigestive tract anastomosis for transanastomotic pancreatic juice drainage is safe and feasible.