• Drainage
• Endosonography
• Gastrointestinal endoscopy
• Pancreatic ducts
• Pancreaticoduodenectomy

• Biliary duct stenosis
• Biliary leakage
• Bronchopleural fistula
• Pancreatic fistula
• Transgastric drainage

• endoscopic retrograde cholangiopancreatography
• endosonography
• pancreatic duct stents
• surgery

• 82070664 National Natural Science Foundation of China
• 19DZ2201900 Shanghai Science and Technology Innovation Action Plan
• 20SG36 Shanghai Shuguang Program

Pancreatojejunostomy stricture (PJS) is a rare long-term complication of pancreaticojejunal anastomosis. This study aimed to investigate the role of surgery in the management of pancreatojejunostomy strictures.

The database of the Pancreas Center of Nanjing Medical University was retrospectively screened for patients who underwent a surgical revision for PJS between June 2012 and August 2019, and their clinical characteristics and management modalities were reviewed.

Fourteen consecutive cases were retrieved, the median age at index operation was 41.1 years (19–71). The average time between the two operations was 70.6 months (8–270 months). Index procedures included pancreaticoduodenectomy (PD) (7/14, 50%), pylorus-preserving PD (4/14, 28.6%), Berger procedure (2/14, 14.3%), and middle pancreatectomy (1/14, 7.1%). The diameter of the main pancreatic duct was < 4 mm in all 14 cases, and nine underwent pancreaticojejunostomy (PJ) stenting during the index operation. The most frequent complaints were abdominal pain (6/14, 42.9%), recurrent acute pancreatitis (6/14, 42.9%), pancreatic fistula (1/14, 7.1%), and abdominal distention (1/14, 7.1%). The diagnosis of PJ stricture was confirmed by computed tomography or magnetic resonance imaging in all cases. All patients had a main duct diameter > 5 mm before surgical revision. All patients underwent wedge excision with interrupted one-layer suturing with absorbable sutures and without stent placement. In this series, only one patient required reoperation. Upon follow-up, 11 of 12 patients had complete resolution of the PJ stricture.

PJS is a long-term complication of pancreatojejunostomy. Surgical revision of the anastomosis is a safe and effective treatment modality.

• Long-term complications
• Pancreatojejunostomy stricture case series
• Pancreatomy
• Surgical revision

Familial adenomatous polyposis (FAP) patients with Spigelman stage IV polyposis should be considered for prophylactic duodenectomy. Post‐surgical pancreaticobiliary complications occur and may require management via endoscopic retrograde cholangiopancreatography (ERCP). We aimed to assess the success and adverse events of ERCP in FAP patients after pancreas‐sparing duodenectomy (PSD) and pancreaticoduodenectomy (PD).

A retrospective review of FAP patients who underwent ERCP after PSD or PD from 1992 to 2020 at a quaternary referral center was completed. The technical success of ERCP was defined as the ability to identify the anastomosis and cannulate the duct. Post‐procedural adverse events were defined by bleeding, perforation, pancreatitis, or cholangitis. Clinical outcomes included the need for surgical intervention and recurrent pancreatitis after ERCP were assessed.

Of 84 FAP patients with duodenectomy, 12 patients with PSD and two patients with PD underwent 17 ERCPs for pancreatic indications and five for biliary indications. The technical success of ERCP in patients with PSD and a single neoampullary complex for pancreatic (n = 6) and biliary (n = 5) indications was 100% but for those with PD (n = 2) or PSD reconstruction with pancreatic divisum or separate anastomoses (n = 3), it was 0%. Surgical intervention was required in 50% of patients with technically failed ERCP after PSD (2/4) and PD (1/2). There were no adverse events.

ERCP is expected to be therapeutically successful for biliary complications following PSD. Assessment and potential therapy for pancreatitis post‐PSD are best in the setting of a single neo‐ampullary complex rather than in PD or PSD with pancreatic divisum.

• Chronic pancreatitis
• ERCP
• EUS-PD
• Endoscopic ultrasonography
• Endoscopic ultrasound guided pancreatic duct drainage

• Constriction, Pathologic
• Drainage/methods
• Endosonography/methods
• Female
• Humans
• Male
• Middle Aged
• Pancreatic Ducts/diagnostic imaging
• Pancreatic Ducts/surgery
• Pancreatitis, Chronic/diagnostic imaging
• Pancreatitis, Chronic/surgery
• Retrospective Studies
• Treatment Outcome
• Ultrasonography, Interventional

• balloon enteroscopy
• endoscopic retrograde cholangiopancreatography
• pancreatic fistula
• pancreatic stone
• pancreaticojejunostomy anastomotic stricture

There is limited evidence supporting the usefulness of endoscopic retrograde pancreatic drainage (ERPD) for symptomatic pancreaticojejunal anastomotic stenosis (sPJS). We examined the usefulness of ERPD for sPJS. We conducted a retrospective analysis of 10 benign sPJS patients. A forward-viewing endoscope was used in all sessions. Following items were evaluated: technical success, adverse events, and clinical outcome of ERPD. The technical success rate was 100% (10/10) in initial ERPD; 9 patients had a pancreatic stent (no-internal-flap: n = 4, internal-flap: n = 5). The median follow-up was 920 days. Four patients developed recurrence. Among them, 3 had a stent with no-internal-flap in initial ERPD, the stent migrated in 3 at recurrence, and a stent was not placed in 1 patient in initial ERPD. Four follow-up interventions were performed. No recurrence was observed in 6 patients. None of the stents migrated (no-internal-flap: n = 1, internal-flap: n = 5) and no stents were replaced due to stent failure. Stenting with no-internal-flap was associated with recurrence (p = 0.042). Mild adverse events developed in 14.3% (2/14). In conclusions, ERPD was performed safely with high technical success. Recurrence was common after stenting with no-internal-flap. Long-term stenting did not result in stent failure.

Clinical trial register and their clinical registration number: Nos. 58-115 and R2-9.

Endoscopic ultrasound (EUS)-guided interventions provide easy access to structures adjacent to the gastrointestinal tract, effectively targeting them for therapeutic purposes. They play an important role in the management of pancreatic fluid collections (PFC) and bile duct (BD) and pancreatic duct (PD) drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) or gallbladder (GB) drainage. Specially designed stents and delivery systems for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. In fact, EUS-guided drainage has emerged as the treatment of choice for the management of PFC, and recent innovations such as fully covered metal stents (including lumen-apposing metal stents) have improved outcomes in patients with walled-off necrosis. Similarly, EUS-guided BD and PD drainage with specially designed stents can be beneficial for patients with failed ERCP due to an inaccessible papilla, gastric outlet obstruction, or surgically altered anatomy. EUS-guided GB drainage is also performed using dedicated stents in patients with acute cholecystitis who are not fit for surgery. Although the field of dedicated stents for interventional EUS is rapidly advancing with increasing innovations, the debate on the most appropriate stent for EUS-guided drainage has resurfaced. Furthermore, some important questions remain unaddressed, such as which stent improves clinical outcomes and safety in EUS-guided drainage. Herein, the current status and problems of the available stents are reviewed, including the applicable indications, long-term clinical outcomes, comparison between each stent, and their future prospects.

• drainage
• endoscopic ultrasound
• intervention
• stents
• therapeutic

• bile duct stone
• biliary stenting
• interventional EUS
• rendezvous technique
• surgical altered anatomy

• ERCP
• anastomotic stenosis
• balloon-assisted endoscopy
• choledochojejunostomy
• pancreaticojejunostomy

• Acute pancreatitis
• Pancreaticoduodenectomy
• Pancreaticojejunostomy stricture
• Pancreatoenteric anastomotic stricture
• Whipple operation

• Endoscopic ultrasound
• pancreatic duct obstruction
• rendezvous
• transmural drainage

• Late complication
• Pancreatic anastomosis stricture
• Pancreaticoduodenectomy
• Pancreaticojejunostomy stricture
• Pancreatitis

• Anastomosis
• Pancreaticogastrostomy
• Pancreaticojejunostomy
• Pancreatoduodenectomy
• Stenosis

• EUS-PDD, EUS-guided pancreatic duct drainage
• FV, forward-viewing
• PJS, pancreaticojejunostomy stricture

• anastomotic stricture
• pancreaticoduodenectomy
• pancreaticojejunostomy complication

• Amylase
• Infected pancreatic necrosis
• Nasopancreatic drainage
• Pancreatic duct disruption
• Pancreatic fistula

Endoscopic retrograde cholangiopancreatography (ERCP) has become the mainstay of therapy for pancreatobiliary diseases. While ERCP is safe and highly effective in the general population, the procedure remains challenging or impossible in patients with surgically altered anatomy (SAA). Endoscopic ultrasound (EUS) allows transmural access to the bile or pancreatic duct (PD) prior to ductal drainage using ERCP-based techniques. Also known as endosonography-guided cholangiopancreatography (ESCP), the procedure provides multiple advantages over overtube-assisted enteroscopy ERCP or percutaneous or surgical approaches. However, the procedure should only be performed by endoscopists experienced in both EUS and ERCP and with the proper tools. In this review, various EUS-guided diagnostic and therapeutic drainage techniques in patients with SAA are examined. Detailed step-by-step procedural descriptions, technical tips, feasibility, and safety data are also discussed.

• Antegrade drainage
• Endoscopic ultrasound
• Rendezvous
• Surgically altered anatomy
• Transmural drainage

For diagnosis and treatment of pancreatobiliary diseases, endoscopic retrograde cholangiopancreatography (ERCP) is useful method nowadays and its technically success rate is usually in about 90%-95% of patients with normal gastric and pancreaticobiliary anatomy. Recently ERCP is significantly challenging after intestinal reconstruction, particularly in patients who have undergone pancreaticoduodenectomy (PD, classic Whipple’s operation) or pylorus-preserving pancreatoduodenectomy (PPPD) with reconstruction. PD and PPPD relate to numerous techniques have been presented for reconstruction of the digestive tract and pancreaticobiliary tree during the resection bilioenteric stricture commonly occurs later in the postoperative course and developed in 5-year cumulative probability of biliary stricture rate of 8.2% and pancreaticoenteric stricture of 4.6%. This complication was no difference in incidence between patients with benign or malignant disease. In PD or PPPD with reconstruction, short pancreatobiliary limb with biliojejunal anastomosis site is made usually, modestly success rate of intubation to blind loop and cannulation with conventional endoscope. However, in combined Reux-en-Y anastomosis, longer pancreatobiliary limb and additional Reux limb are obstacle to success intubation and cannulation by using conventional endoscope. In this situation, new designed enetroscope with dedicated accessories is efficient.

• ERCP
• Pancreaticoduodenectomy
• Pylorus-preserving pancreatoduodenectomy

• anastomotic stricture
• endoscopic characteristics
• endoscopic dilatation
• pancreaticojejunostomy
• pancreatitis

The management of pancreaticobiliary disease in patients with surgically altered anatomy is a growing problem for gastroenterologists today. Over the years, endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the treatment of pancreaticobiliary disease. Patient anatomy has become increasingly complex due to advances in surgical resection of pancreaticobiliary disease and EUS has emerged as the therapy of choice when endoscopic retrograde cholangiopancreatography failed cannulation or when the papilla is inaccessible such as in gastric obstruction or duodenal obstruction. The current article gives a comprehensive review of the current literature for EUS-guided intervention of the pancreaticobiliary tract in patients with altered surgical anatomy.

• Biliary tract
• endosonography
• major pancreatic duct
• surgically altered anatomy

Despite the advances in endoscopy, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) remains a technically challenging procedure. Technical success rates are greater than 70%; however, the average rate of adverse events is nearly 20%, which increases to 55% when stent migration is included. Until recently, a significant difficulty with this technique was the absence of dedicated devices. Proper patient selection is of utmost importance, and EUS-PDD should be reserved for patients who have failed endoscopic retrograde pancreatography. Furthermore, EUS-PDD must be performed by experienced endoscopists who are familiar with the technique. The most common indications include chronic pancreatitis induced strictures and stones, disconnected pancreatic ducts, inaccessible ampulla, and post-surgical altered anatomy. This manuscript will review the accessories used, techniques employed, and published literature reporting outcomes as well as adverse events regarding EUS-PDD.

• Drainage
• Endosonography
• Pancreatic duct intervention
• Pancreatic ducts
• Stents

• Aged
• Aged, 80 and over
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Double-Balloon Enteroscopy/methods
• Female
• Gallbladder Diseases/surgery
• Gastrectomy
• Humans
• Male
• Middle Aged
• Reoperation
• Retrospective Studies

• Balloon-assisted enteroscope
• Conventional endoscope
• ERCP
• Pancreaticoduodenectomy

• COLONIC POLYPS
• COLORECTAL ADENOMAS
• ENDOSCOPIC POLYPECTOMY
• ENDOSCOPY
• SURGICAL RESECTION

• Anticoagulants/administration & dosage
• Colonic Polyps/pathology
• Colonic Polyps/surgery
• Colonic Polyps/therapy
• Endoscopy, Gastrointestinal
• Humans
• Interdisciplinary Communication
• Ireland
• Patient Education as Topic
• Platelet Aggregation Inhibitors/administration & dosage
• Quality Indicators, Health Care
• Rectal Diseases/pathology
• Rectal Diseases/surgery
• Rectal Diseases/therapy
• United Kingdom

• Bile duct
• Biliary drainage
• Endoscopic retrograde cholangio-pancreatography
• Endoscopic ultrasound
• Pancreatic drainage
• Pancreatic duct
• Percutaneous transhepatic cholangiography

• Endosonography · Interventional · Pancreatogram · Stent · Therapeutic

• Endoscopic ultrasound
• Pancreatoduodenectomy
• Strictured pancreatojejunal anastomosis
• Transjejunal puncture

• ERP
• MPD
• endoscopic retrograde pancreatography
• main pancreatic duct

• Endoscopic ultrasonogaraphy
• Interventional endoscopic ultrasonogaraphy
• Pancreatic duct drainage
• Surgical altered anatomy

• Endoscopic retrograde cholangiopancreatography
• Endoscopic ultrasonography
• Pancreatic access
• Pancreatic drainage
• Pancreaticogastrostomy

The patient was a 30-year-old female who had undergone excision of the extrahepatic bile duct and Roux-en-Y hepaticojejunostomy for congenital biliary dilatation at the age of 7. Thereafter, she suffered from recurrent acute pancreatitis due to pancreaticobiliary maljunction and received subtotal stomach-preserving pancreaticoduodenectomy. She developed a pancreatic fistula and an intra-abdominal abscess after the operation. These complications were improved by percutaneous abscess drainage and antibiotic therapy. However, upper abdominal discomfort and the elevation of serum pancreatic enzymes persisted due to stenosis from the pancreaticojejunostomy. Because we could not accomplish dilation of the stenosis by endoscopic retrograde cholangiopancreatography, we tried an endoscopic ultrasonography (EUS) guided rendezvous technique for pancreatic duct drainage. After transgastric puncture of the pancreatic duct using an EUS-fine needle aspiration needle, the guidewire was inserted into the pancreatic duct and finally reached to the jejunum through the stenotic anastomosis. We changed the echoendoscope to an oblique-viewing endoscope, then grasped the guidewire and withdrew it through the scope. The stenosis of the pancreaticojejunostomy was dilated up to 4 mm, and a pancreatic stent was put in place. Though the pancreatic stent was removed after three months, the patient remained symptom-free. Pancreatic duct drainage using an EUS-guided rendezvous technique was useful for the treatment of a stenotic pancreaticojejunostomy after pancreaticoduodenectomy.

• Balloon dilatation
• Endoscopic ultrasound-guided fine needle aspiration
• Pancreaticobiliary maljunction
• Pancreaticoduodenectomy
• Pancreatitis
• Postoperative complication

• Adult
• Constriction, Pathologic
• Dilatation, Pathologic
• Drainage/instrumentation
• Drainage/methods
• Endosonography
• Female
• Humans
• Magnetic Resonance Imaging
• Pancreatic Ducts/pathology
• Pancreatic Ducts/surgery
• Pancreaticojejunostomy/adverse effects
• Postoperative Complications/diagnosis
• Postoperative Complications/therapy
• Punctures
• Stents
• Tomography, X-Ray Computed
• Treatment Outcome

• Anastomotic stricture
• Endoscopic ultrasound (EUS)-guided pancreatic duct drainage
• Pancreaticoduodenectomy
• Pancreaticogastrostomy
• Pancreaticojejunostomy