Endoscopic approach for a pinhole-like benign stenosis in a pancreaticojejunal anastomosis using a double-balloon endoscope with a clear long cap attachment

The usefulness of therapeutic modalities using double-balloon endoscopy for biliary disease in postoperative patients has been widely reported ^{1 2 3} , while papers published about its use in pancreatic disease are scarce, despite an increasing demand for such treatment. This is the first report of successful double-balloon endoscopy-assisted endoscopic retrograde pancreatography (DB-ERP) using a clear long cap for a pinhole-like benign stricture in the pancreaticojejunal anastomosis after pancreaticoduodenectomy.

A 63-year-old woman who had undergone pancreaticoduodenectomy for a lower bile duct cyst with abnormal confluence suffered recurrent pancreatitis 1 year after surgery. Obstructive pancreatitis due to stenosis in the pancreaticojejunal anastomosis was suspected on imaging ( Fig. 1 ). The main pancreatic duct (PD) was mildly dilated, which posed a risk for intervention by endoscopic ultrasound (EUS), so we decided to perform DB-ERP instead. A clear long cap ( Fig. 2 ) was attached in an attempt to make any endoscopic maneuvers smoother. The expected advantages of this were: to allow it to be pressed against the intestinal wall, so that even sutures covered by mucosa could be easily detected; to allow the pancreaticojejunal anastomosis to be shown in the vertical direction, instead of the normal tangential direction; to allow a certain distance to be maintained between the endoscope and the pancreaticojejunal anastomosis, which would enable smooth endoscopic procedures and blind maneuvers to be avoided.

Fig. 1 .

Image from a preprocedure computed tomography scan showing mild pancreatic duct dilatation.

Fig. 2.

 Photograph showing the difference between the clear long cap (left) and a conventional cap (right).

First, the pancreaticojejunal anastomosis was identified by fluoroscopic image, and the sutures fixing the pancreas and jejunum were then detected endoscopically ( Fig. 3 a ). By careful observation in the area of the sutures, the scar-like mucosa and the pinhole-like stricture of the pancreaticojejunal anastomosis were successfully identified ( Fig. 3 b ). Pancreatography and deep cannulation were performed successfully, and were followed by anastomotic dilation and PD stenting ( Video 1 ). Following the successful completion of DB-ERP, the patient was discharged on the fourth day, without experiencing any major complications or any further pancreatitis.

Fig. 3.

 Endoscopic views showing: a the suture (arrow) fixing the pancreas and jejunum; b a scar-like ulcer in the mucosa, with a pinhole-like stenosis of the pancreaticojejunal anastomosis at its center (arrow).

Video 1  A double-balloon endoscope with a clear long cap attached is successfully used to identify a pinhole-like benign stenosis in a pancreaticojejunal anastomosis, which then allowed pancreatography and deep cannulation to be successfully performed, prior to anastomotic dilation and pancreatic duct stenting.

Download video file ^{(55.6MB, mp4)}

EUS intervention is reported to be effective for pancreatic diseases ^{4 5} , yet it is invasive for postoperative cases and only used selectively. In conclusion, double-balloon endoscopy approaches can be safely used in patients with a mildly dilated PD, and DB-ERP using a clear long cap is effective for pancreaticojejunal anastomosis stenosis in symptomatic patients.

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