Patient characteristics
A total of 10 patients who were diagnosed with sPJS underwent ERPD. Study subjects had a median age of 64.5 (45-83), and consisted of 6 male and 4 female patients. Primary diseases that led to the surgery included pancreatic cancer (n=3), intraductal papillary mucinous neoplasm (n=4), biliary tract cancer (n=2), and papillary carcinoma of the duodenum (n=1). Surgical procedures and reconstruction methods employed included pylorus-preserving pancreaticoduodenectomy (PpPD) with modified-Child’s reconstruction (n=8), PpPD with Cattell’s reconstruction (n=1), and subtotal stomach-preserving PD (SSpPD) with modified-Child’s reconstruction (n=1). The cause of sPJS was benign stenosis in all 10 patients. Clinical symptoms of sPJS included recurrent acute pancreatitis (n=8), and glucose intolerance and exocrine pancreatic insufficiency (n=2) (Table. 1).
Endoscopic identification of the anastomotic site
The anastomotic site was accessible and identified in all 10 patients. In 9 patients who underwent PpPD and SSpPD with modified-Child’s reconstruction, the anastomotic sites were located tangent to the endoscopic view. In the remaining 1 patient who underwent PpPD with Cattell’s reconstruction, the anastomotic site was located frontward to the endoscopic view. Anastomotic sites were characterized by the presence of erosion (n=1), pitted scars (n=6), and slit (n=3) (Figure.1). A tip attachment was used for all 10 patients to facilitate identification of the anastomotic sites. In 1 patient whose anastomotic site was characterized by the presence of pitted scars, the site was identified by imaging the remnant main pancreatic duct by EUS using a small-diameter probe. In the other 3 patients whose anastomotic site was characterized by the presence of pitted scars, the sites were identified by contrast imaging of the pancreatic duct using an injection needle (Table. 2).
ERPD for sPJS
For patients with symptoms of pancreatitis, ERPD was performed only after those symptoms improved. A tip attachment was applied to an endoscope (GIF-H290, GIF-2TQ260M, PCF-PQ260I, PCF-H290I, PCF-H290ZI, CF-HQ290ZI, and SIF-H290S; Olympus Medical Systems, Tokyo, Japan, and EN450BI5, and EI530B; Fujifilm Medical, Tokyo, Japan). When the anastomotic site was able to be identified, endoscopic retrograde pancreatography (ERP) was performed using a contrast cannula (TandemXL, and Swish ERCP cannula; Boston Scientific Japan, Tokyo, Japan, and PR-109Q, PR-110Q, and PR-V234Q; Olympus Medical Systems, and MTW ERCP-Catheter; MTW Endoscopie Manufaktur, Wesel, Germany). After ERP, a guidewire (VisiGlide, and VisiGlide2 angle; Olympus Medical Systems, and Roadrunner; Cook Medical, Wilston-Salem, NC, United States, and M-Through; Medico’s Hirata, Tokyo, Japan) was placed in the pancreatic duct. When ERP was unable to be directly applied, wire-guided technique (WGT) was concomitantly employed. In some cases, the anastomotic site was identified by pancreatography of the suspected site using an injection needle (23G Top endoscopic injection needle, TOP, Tokyo, Japan) to ensure that the remnant main pancreatic duct can be observed or by EUS using a small-diameter probe (UMQ240; Olympus Medical Systems) to identify the remnant main pancreatic duct. When cannulation was challenging due to scarring of the anastomotic site, it was effective to either make an incision to the anastomotic site using a needle knife (KD-1L-1; Olympus Medical Systems) or insert a 19G needle (EZ Shot 3 Plus; Olympus Medical Systems) into the anastomotic site using a forward-viewing echoendoscope (TGF-UC260J; Olympus Medical Systems). After placing the guidewire in the pancreatic duct, the anastomotic site was dilated using a cannula or a balloon dilator (MaxPass; Olympus Medical Systems, and Hurricane RX Biliary Balloon Dilatation Catheter, and CRE PRO GI Wireguided; Boston Scientific Japan, and ZARA EPBD balloon; KANEKA, Tokyo, Japan) or a dilator (ES dilator; Zeon Medical, Tokyo, Japan). When a pancreatic calculi was present, it was removed using a basket catheter (Xemex lithotripsy basket; Zeon Medical, and Memory II 8 Fr Eight Wire Double Lumen Baskets; Cook Medical) or electrohydraulic lithotripsy by pancreatoscopy (SpyGlass DS; Boston Scientific Japan). Lastly, either a pancreatic stent with no-internal-flap or with internal-flap (Geenen Pancreatic Stent, and Zimmon Pancreatic Stent; Cook Medical, and Advanix Pancreatic Stent; Boston Scientific Japan) was placed (Figure. 2).
ERP was performed and a guidewire was placed successfully in all 10 patients after identifying the anastomotic sites. The methods of ERP and guidewire placement for each anastomotic site are summarized in Table. 3. In one patient whose anastomotic site was characterized by the presence of erosion, ERP and guidewire placement were facilitated by the use of WGT. Among 3 patients whose anastomotic site was characterized by the presence of a slit, ERP and guidewire placement were successfully performed with cannulation alone in 2 patients, whereas the use of WGT was required in 1 patient. Among 6 patients whose anastomotic site was characterized by the presence of pitted scars, ERP and guidewire placement were successfully performed with cannulation alone in 1 patient, whereas the remaining patients required the use of WGT (n=1), WGT and incision of the anastomotic site with a needle knife (n=1), the use of an injection needle and WGT (n=1), and the use of an injection needle, WGT, and incision of the anastomotic site with a needle knife (n=2).
Following the placement of a guidewire, anastomotic sites were successfully dilated in all 10 patients. Anastomotic sites were dilated with a balloon (n=7), a dilator (n=1), and a dilation for contrast cannula (n=2). For the 7 patients who underwent dilation of their anastomotic sites with a balloon, the median diameter of the remnant main pancreatic duct was 7 mm (5-9 mm) and that of the balloon dilation was 6 mm (3.3-8 mm). The median ratio of the diameters of balloon dilation to that of the remnant main pancreatic duct was 0.86 (0.47-1.60), and waist disappearance was observed in 5 patients. There were 2 patients who were performed balloon dilations exceeding the ratio of 1.00 (1.33 and 1.60). In these two patients, balloon dilations with the diameters of balloon exceeding that of the remnant main pancreatic duct were needed to obtain waist disappearance. A pancreatic stent was placed in 9 patients (with no-internal-flap: n=4, with internal-flap: n=5). The sizes of these stents were 4 Fr (n=1), 5 Fr (n=6), and 7 Fr (n=2). In the remaining 1 patient, a stent was not placed because waist disappearance was observed with a balloon and dilation of the anastomotic site was confirmed on endoscopy. Pancreatic calculi were removed from 2 patients (Table. 3).
Recurrence of sPJS after ERPD
The median follow-up after initial ERPD was 920 days (137-2,223 days). Of the 10 patients, 4 developed recurrent sPJS in a median of 540 days (33-1,865 days) after initial ERPD. For 4 recurrent sPJS, anastomotic sites of the initial ERPD were characterized by the presence of pitted scars (n=2) and slit (n=2). Although all 4 patients underwent balloon dilation of the anastomotic site in initial ERPD, only 2 achieved waist disappearance. Pancreatic calculi were identified in one patient with recurrent sPJS, even though calculi were removed in initial ERPD. Pancreatic stents with no-internal-flap were used in 3 of 4 patients in initial ERPD, and the stent migrated in all 3 patients at recurrence. These stents were 5 Fr (n=2) and 7 Fr (n=1) in size. A pancreatic stent was not placed in the remaining 1 patient in initial ERPD (Table. 4). A total of 4 follow-up ERPD were performed in 3 of 4 patients with recurrent sPJS. Two patients underwent 1 follow-up ERPD and were treated successfully, whereas the remaining 1 patient required 2 follow-up ERPD. Another 1 patient did not wish to undergo follow-up ERPD. ERPD was therefore not performed and the patient has had multiple recurrences of sPJS. In one of the patients who was successfully treated by 1 follow-up ERPD, the anastomotic site was characterized by the presence of a slit in initial ERPD. However, at recurrence, significant scarring was observed at the anastomotic site and an incision with a needle knife was required. In the patient who required 2 follow-up ERPD, the anastomotic site was initially characterized by the presence of pitted scars. However, there was significant scarring at the anastomotic site at recurrence. Thus, the first follow-up ERPD was not successful. In the second follow-up ERPD, a forward-viewing echoendoscope was inserted into the anastomotic site, and the anastomotic site was punctured with a 19G needle and subsequently dilated with a dilator to successfully perform ERPD.9
Six patients didn’t have recurrent sPJS. The median follow-up in these patients was 292 days (137-1,000 days). None of the pancreatic stents placed in these patients migrated and none were replaced pancreatic stents during the follow-up period. Among them, 5 patients had pancreatic stents with internal-flap and 1 patient had a pancreatic stent with no-internal-flap. The sizes of these stents were 4 Fr (n=1), 5 Fr (n=4), and 7 Fr (n=1).
On univariate analysis, the use of a pancreatic stent with no-internal-flap was identified as a risk factor for sPJS recurrence (p=0.042) (Table. 5).
AE after ERPD
AE developed in 14.3% of all cases (2/14). These AE were mild post endoscopic retrograde pancreatography pancreatitis (PEP) (n=1) and anastomotic leak due to balloon dilation (n=1). The patient with mild PEP did not have a pancreatic stent placed. In the second patient, anastomotic leak was identified after the patient presented with abdominal pain after ERPD. Both of these AE were treated successfully by conservative treatments.