Endoscopic management of pancreatic diseases in patients with surgically altered anatomy: clinical outcomes of combination of double-balloon endoscopy- and endoscopic ultrasound-guided interventions
Hirofumi Kogure
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorTatsuya Sato
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorCorresponding Author
Yousuke Nakai
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Department of, Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Corresponding: Yousuke Nakai, Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. Email: [email protected]
Search for more papers by this authorKazunaga Ishigaki
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorRyunosuke Hakuta
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorKei Saito
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorTomotaka Saito
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorNaminatsu Takahara
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorTsuyoshi Hamada
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorSuguru Mizuno
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorAtsuo Yamada
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorMinoru Tada
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorHiroyuki Isayama
Department of, Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
Search for more papers by this authorKazuhiko Koike
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorHirofumi Kogure
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorTatsuya Sato
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorCorresponding Author
Yousuke Nakai
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Department of, Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Corresponding: Yousuke Nakai, Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. Email: [email protected]
Search for more papers by this authorKazunaga Ishigaki
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorRyunosuke Hakuta
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorKei Saito
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorTomotaka Saito
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorNaminatsu Takahara
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorTsuyoshi Hamada
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorSuguru Mizuno
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorAtsuo Yamada
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorMinoru Tada
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorHiroyuki Isayama
Department of, Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
Search for more papers by this authorKazuhiko Koike
Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorKogure and Sato contributed equally as co-first authors.
Abstract
Objectives
In patients with surgically altered anatomy, endoscopic treatment of pancreatic diseases is technically challenging. We aimed to evaluate the feasibility, effectiveness, and safety of an interchangeable combination of double-balloon endoscope-assisted ERP (DB-ERP) and endoscopic ultrasonography-guided pancreatic duct drainage (EUS-PD) in this clinical setting.
Methods
Consecutive patients with surgically altered anatomy undergoing endoscopic treatment (DB-ERP, EUS-PD, or both) for pancreatic diseases were studied. The primary outcome was technical success; secondary outcomes were clinical success and adverse events.
Results
Forty patients who underwent DB-ERP (38) and EUS-PD (2) as an initial intervention were retrospectively studied. Indications for intervention included 18 pancreaticojejunostomy anastomotic stricture (PJAS), four pancreatic duct stone (PDS), four pancreatic fistula (PF), 11 PJAS with PDS, and three PJAS with PF. Prior surgical reconstruction was 26 Billroth-II, 13 Roux-en-Y, and one Imanaga reconstruction. Along with salvage procedures including three DB-ERP and seven EUS-PD, the overall technical success rates of DB-ERP and EUS-PD were 70.7% (29/41) and 100% (9/9), respectively. Clinical success was achieved in 85.0% (34/40) by combination of DB-ERP and EUS-PD; successful drainage for PJAS, complete removal of PDS, and resolution of PF were achieved in 90.6%, 80.0%, and 71.4%, respectively. Adverse event rates were 12.2% (5/41; one perforation, and four pancreatitis) in DB-ERP and 55.6% (5/9; three pancreatic leakage, and two abdominal pain) in EUS-PD.
Conclusions
A combination of DB-ERP and EUS-PD can achieve high technical and clinical success for pancreatic diseases in surgically altered anatomy patients. A prospective multicenter study to investigate an appropriate treatment algorithm is warranted.
Conflict of Interest
Author Y.N. is an Associated Editor of Digestive Endoscopy. Other authors have no COI to disclose.
Supporting Information
| Filename | Description |
|---|---|
| den13746-sup-0001-Supinfo.docxWord 2007 document , 155.6 KB |
Figure S1 Clinical outcomes of endoscopic management for pancreaticojejunostomy anastomotic stricture in patients with surgically altered anatomy. DB-ERP, double-balloon endoscope-assisted endoscopic retrograde pancreatography; EUS-PD, endoscopic ultrasonography-guided pancreatic duct drainage; EUS-RV, endoscopic ultrasonography-guided rendezvous technique; PJAS, pancreaticojejunostomy anastomotic stricture. Figure S2 Clinical outcomes of endoscopic management for pancreatic duct stones in patients with surgically altered anatomy. DB-ERP, double-balloon endoscope-assisted endoscopic retrograde pancreatography; EUS-PD, endoscopic ultrasonography-guided pancreatic duct drainage; PDS, pancreatic duct stone. Figure S3 Clinical outcomes of endoscopic management for pancreatic fistula in patients with surgically altered anatomy. DB-ERP, double-balloon endoscope-assisted endoscopic retrograde pancreatography; EUS-PD, endoscopic ultrasonography-guided pancreatic duct drainage; EUS-RV, endoscopic ultrasonography-guided rendezvous technique; PF, pancreatic fistula. Table S1 Patient characteristics and outcomes of EUS-PD as the initial and salvage procedures. |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
References
- 1Chahal P, Baron TH, Topazian MD, Petersen BT, Levy MJ, Gostout CJ. Endoscopic retrograde cholangiopancreatography in post-Whipple patients. Endoscopy 2006; 38: 1241–5.
- 2Farrell J, Carr-Locke D, Garrido T, Ruymann F, Shields S, Saltzman J. Endoscopic retrograde cholangiopancreatography after pancreaticoduodenectomy for benign and malignant disease: Indications and technical outcomes. Endoscopy 2006; 38: 1246–9.
- 3Kikuyama M, Itoi T, Ota Y et al. Therapeutic endoscopy for stenotic pancreatodigestive tract anastomosis after pancreatoduodenectomy (with videos). Gastrointest Endosc 2011; 73: 376–82.
- 4Aabakken L, Bretthauer M, Line PD. Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis. Endoscopy 2007; 39: 1068–71.
- 5Emmett DS, Mallat DB. Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: A case series. Gastrointest Endosc 2007; 66: 1038–41.
- 6Itoi T, Ishii K, Sofuni A et al. Single-balloon enteroscopy-assisted ERCP in patients with Billroth II gastrectomy or Roux-en-Y anastomosis (with video). Am J Gastroenterol 2010; 105: 93–9.
- 7Azeem N, Tabibian JH, Baron TH et al. Use of a single-balloon enteroscope compared with variable-stiffness colonoscopes for endoscopic retrograde cholangiography in liver transplant patients with Roux-en-Y biliary anastomosis. Gastrointest Endosc 2013; 77: 568–77.
- 8Shimatani M, Hatanaka H, Kogure H et al. Diagnostic and therapeutic endoscopic retrograde cholangiography using a short-type double-balloon endoscope in patients with altered gastrointestinal anatomy: A multicenter prospective study in Japan. Am J Gastroenterol 2016; 111: 1750–8.
- 9Kogure H, Watabe H, Yamada A et al. Spiral enteroscopy for therapeutic ERCP in patients with surgically altered anatomy: Actual technique and review of the literature. J Hepatobiliary Pancreat Sci 2011; 18: 375–9.
- 10Shah RJ, Smolkin M, Yen R et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc 2013; 77: 593–600.
- 11Yamada A, Kogure H, Nakai Y et al. Performance of a new short-type double-balloon endoscope with advanced force transmission and adaptive bending for pancreaticobiliary intervention in patients with surgically altered anatomy: A propensity-matched analysis. Dig Endosc 2019; 31: 86–93.
- 12Sato T, Kogure H, Nakai Y et al. Double-balloon endoscopy-assisted treatment of hepaticojejunostomy anastomotic strictures and predictive factors for treatment success. Surg Endosc 2020; 34: 1612–20.
- 13Yane K, Katanuma A, Maguchi H et al. Short-type single-balloon enteroscope-assisted ERCP in postsurgical altered anatomy: Potential factors affecting procedural failure. Endoscopy 2017; 49: 69–74.
- 14Layec S, D'Halluin P-N, Pagenault M, Sulpice L, Meunier B, Bretagne J-F. Removal of transanastomotic pancreatic stent tubes after pancreaticoduodenectomy: A new role for double-balloon enteroscopy. Gastrointest Endosc 2010; 72: 449–51.
- 15Menon KVN, Sanaka M. Successful single-balloon enteroscopic dilation of late anastomotic pancreaticojejunostomy stricture following whipple procedure. Pancreas 2010; 39: 115–6.
- 16Park J-H, Ye BD, Byeon J-S et al. Approaching pancreatic duct through pancreaticojejunostomy site with double ballon enteroscope in patients with Roux-en-Y anatomy. Hepatogastroenterology 2013; 60: 1753–8.
- 17Bataille L, Deprez P. A new application for therapeutic EUS: Main pancreatic duct drainage with a “pancreatic rendezvous technique”. Gastrointest Endosc 2002; 55: 740–3.
- 18Fujii LL, Topazian MD, Abu Dayyeh BK et al. EUS-guided pancreatic duct intervention: Outcomes of a single tertiary-care referral center experience. Gastrointest Endosc 2013; 78: 854–64.e1.
- 19Itoi T, Kasuya K, Sofuni A et al. Endoscopic ultrasonography-guided pancreatic duct access: Techniques and literature review of pancreatography, transmural drainage and rendezvous techniques. Dig Endosc 2013; 25: 241–52.
- 20Dhir V, Isayama H, Itoi T et al. Endoscopic ultrasonography-guided biliary and pancreatic duct interventions. Dig Endosc 2017; 29: 472–85.
- 21Ryozawa S, Fujita N, Irisawa A, Hirooka Y, Mine T. Current status of interventional endoscopic ultrasound. Dig Endosc 2017; 29: 559–66.
- 22Nakai Y, Kogure H, Isayama H, Koike K. Endoscopic ultrasound-guided pancreatic duct drainage. Saudi J Gastroenterol 2019; 25: 210–7.
- 23Tyberg A, Sharaiha RZ, Kedia P et al. EUS-guided pancreatic drainage for pancreatic strictures after failed ERCP: A multicenter international collaborative study. Gastrointest Endosc 2017; 85: 164–9.
- 24Dalal A, Patil G, Maydeo A. Six-year retrospective analysis of endoscopic ultrasonography-guided pancreatic ductal interventions at a tertiary referral center. Dig Endosc 2020; 32: 409–16.
- 25Chen YI, Levy MJ, Moreels TG et al. An international multicenter study comparing EUS-guided pancreatic duct drainage with enteroscopy-assisted endoscopic retrograde pancreatography after Whipple surgery. Gastrointest Endosc 2017; 85: 170–7.
- 26Sasahira N, Tada M, Isayama H et al. Outcomes after clearance of pancreatic stones with or without pancreatic stenting. J Gastroenterol 2007; 42: 63–9.
- 27Ogura T, Nakai Y, Itoi T. Novel fine gauge electrocautery dilator for endoscopic ultrasound-guided hepaticogastrostomy (with video). J Hepatobiliary Pancreat Sci 2019; 26: E3–4.
- 28Nakai Y, Kogure H, Koike K. Double-guidewire technique for endoscopic ultrasound-guided pancreatic duct drainage. Dig Endosc 2019; 31(Suppl 1): 65–6.
- 29Cotton PB, Eisen GM, Aabakken L et al. A lexicon for endoscopic adverse events: Report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446–54.
- 30Kanda Y. Investigation of the freely available easy-to-use software ‘EZR' for medical statistics. Bone Marrow Transplant 2013; 48: 452–8.
- 31Bassi C, Marchegiani G, Dervenis C et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017; 161: 584–91.
- 32Reid-Lombardo KM, Ramos-De la Medina A, Thomsen K, Harmsen WS, Farnell MB. Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases. J Gastrointest Surg 2007; 11: 1704–11.
- 33Iwashita T, Nakai Y, Hara K, Isayama H, Itoi T, Park DH. Endoscopic ultrasound-guided antegrade treatment of bile duct stone in patients with surgically altered anatomy: A multicenter retrospective cohort study. J Hepatobiliary Pancreat Sci 2016; 23: 227–33.
- 34James TW, Fan YC, Baron TH. EUS-guided hepaticoenterostomy as a portal to allow definitive antegrade treatment of benign biliary diseases in patients with surgically altered anatomy. Gastrointest Endosc 2018; 88: 547–54.
- 35Jürgensen C, Distler M, Arlt A et al. EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video). Gastrointest Endosc 2019; 89: 311–9.e1.
Citing Literature
