Clinical Endoscopy

Original Articles

Primary endoscopic ultrasound-guided hepaticogastrostomy for biliary drainage prior to pancreatoduodenectomy: a retrospective study in Japan: Nozomi Okuno, Kazuo Hara, Seiji Natsume, Masataka Okuno, Shin Haba, Tomonari Asano, Takamichi Kuwahara, Hiroki Koda, Yasuhiro Shimizu; Received August 18, 2024 Accepted September 16, 2024 Published online February 11, 2025; DOI: https://doi.org/10.5946/ce.2024.218 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Malignant lesions of the pancreatic head can cause obstructive jaundice requiring biliary drainage. However, the effect of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and metal stents on surgical resection remains controversial. This study aimed to investigate the efficacy of primary endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) performed prior to pancreatoduodenectomy, excluding patients with biliary duct cancer.
Methods
We retrospectively analyzed consecutive patients who underwent pancreatoduodenectomy at our institution between January 2019 and December 2022. The patients were divided into three groups: without biliary drainage (n=130), endoscopic biliary stenting (EBS) (n=57), and primary EUS-HGS (n=20).
Results
The positivity rate of the intraoperative bile juice culture was significantly higher in the EBS group (p<0.001). No significant difference was observed among the groups in terms of postoperative adverse events (Clavien-Dindo grade 3 or higher, p=0.784) or the positive rate of peritoneal lavage cytology (p=0.984). Seven patients in the EBS group (12.3%) experienced early adverse events related to biliary drainage (post-ERCP pancreatitis, n=3; acute cholecystitis, n=3; bile duct perforation, n=1), whereas none in the EUS-HGS group experienced adverse events.
Conclusions
Primary EUS-HGS is technically feasible as a preoperative procedure and has no short-term postoperative disadvantages.

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Safety and efficacy of trans-afferent loop endoscopic ultrasound-guided pancreaticojejunostomy for post pancreaticoduodenectomy anastomotic stricture using the forward-viewing echoendoscope: a retrospective study from Japan: Ahmed Sadek, Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara, Toshitaka Fukui, Minako Urata, Takashi Kondo, Yoshitaro Yamamoto, Kenneth Tachi; Clin Endosc 2025;58(2):311-319. Published online August 26, 2024; DOI: https://doi.org/10.5946/ce.2024.089

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is a well-established procedure for managing pancreaticojejunostomy anastomotic strictures (PJAS) post-Whipple surgery. In this study, we examined the effectiveness and safety of EUS-guided pancreaticojejunostomy (EUS-PJS).
Methods
This retrospective, single-arm study was performed at Aichi Cancer Center Hospital on 10 patients who underwent EUS-guided pancreaticojejunostomy through the afferent jejunal loop using a forward-viewing echoendoscope when endoscopic retrograde pancreatography failed. Our primary endpoint was technical success rate, defined as successful stent insertion. The secondary endpoints were early and late adverse events.
Results
A total of 10 patients underwent EUS-PJS between February 2019 and October 2023. The technical success rate was 100%. The median procedure time was 23.5 minutes. No remarkable early or late adverse events related to the procedure, except for fever, occurred in two patients. The median follow-up duration was 9.5 months, and the median number of stent exchanges was two. A stent-free state was achieved in three patients.
Conclusions
EUS-PJS for PJAS management after pancreaticoduodenectomy appears to be an effective and safe procedure with the potential advantages of fewer reinterventions and the creation of a permanent drainage fistula.

Citations

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Transanastomotic Forward-Viewing EUS-Guided Pancreatic Duct Drainage via Afferent Loop for Pancreaticojejunostomy Anastomotic Stricture After Pancreaticoduodenectomy
Tadahisa Inoue, Rena Kitano, Tomoya Kitada, Kazumasa Sakamoto, Satoshi Kimoto, Jun Arai, Kiyoaki Ito
Digestive Diseases and Sciences.2025; 70(1): 413. CrossRef
Management of Pancreaticojejunostomy Strictures: A New Perspective with Forward-Viewing EUS
Radhika Chavan
Digestive Diseases and Sciences.2025; 70(5): 1740. CrossRef
Transforming endoscopic approaches to post-pancreaticoduodenectomy anastomotic strictures: beyond the surface
Yu-Ting Kuo
Clinical Endoscopy.2025; 58(2): 259. CrossRef
Forward-viewing echoendoscope-guided pancreaticojejunostomy for post-pancreaticoduodenectomy stricture
Toru Kaneko, Mitsuhiro Kida, Takahiro Kurosu, Yutaro Saito, Shiori Koyama, Tomohiro Betto, Chika Kusano
Endoscopy.2025; 57(S 01): E384. CrossRef

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Safety and efficacy of endoscopic ultrasound-guided pancreatic duct drainage using a drill dilator: a retrospective study in Japan: Ahmed Sadek, Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara, Toshitaka Fukui, Minako Urata, Takashi Kondo, Yoshitaro Yamamoto, Kenneth Tachi; Clin Endosc 2024;57(5):666-674. Published online June 5, 2024; DOI: https://doi.org/10.5946/ce.2023.272

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: Dilation of the tract before stent deployment is a challenging step in endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD). In this study, we examined the effectiveness and safety of a novel spiral dilator, Tornus ES (Asahi Intec), for EUS-PDD.
Methods
This was a retrospective, single-arm, observational study at Aichi Cancer Center Hospital. The punctured tract was dilated using a Tornus ES dilator in all EUS-PDD cases. Our primary endpoint was the technical success rate of initial tract dilation. Technical success was defined as successful fistula dilation using a Tornus ES followed by successful stent insertion. Secondary endpoints were procedure times and early adverse events.
Results
A total of 12 patients were included between December 2021 and March 2023. EUS-PDD was performed in 11 patients for post-pancreaticoduodenectomy anastomotic strictures and one patient with pancreatitis with duodenal perforation. The technical success rates of stent insertion and fistula dilation using a Tornus ES dilator was 100%. The median procedure time was 24 minutes. No remarkable adverse events related to the procedure were observed, apart from fever, which occurred in 2 patients.
Conclusions
Tract dilation in EUS-PDD using a Tornus ES is effective and safe.

Citations

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Feasibility of endoscopic ultrasound‐guided hepaticogastrostomy using a novel long balloon catheter
Yuichi Takano, Naoki Tamai, Masataka Yamawaki, Jun Noda, Tetsushi Azami, Fumitaka Niiya, Naotaka Maruoka, Tatsuya Yamagami, Masatsugu Nagahama
DEN Open.2025;[Epub] CrossRef
Endoscopic ultrasound-guided pancreatic duct drainage: Progress and future outlook
Si-Yao Wang, Si-Qiao Zhao, Shu-Peng Wang, Yue Zhang, Si-Yu Sun, Sheng Wang
World Journal of Gastrointestinal Surgery.2025;[Epub] CrossRef
A novel spiral dilator for pancreatic duct drainage: catching two birds with one stone
Han Taek Jeong, Jimin Han
Clinical Endoscopy.2024; 57(5): 608. CrossRef
Technical outcomes between a drill dilator and ultra-tapered mechanical dilator during EUS-guided pancreaticogastrostomy: Comparative study
Takeshi Ogura, Saori Ueno, Atsushi Okuda, Nobu Nishioka, Jun Sakamoto, Jun Matsuno, Yuki Uba, Mitsuki Tomita, Nobuhiro Hattori, Junichi Nakamura, Kimi Bessho, Hiroki Nishikawa
Endoscopy International Open.2024;[Epub] CrossRef

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Focused Review Series: Pancreatobiliary endoscopy in altered gastointestinal anatomy

Endoscopic Retrograde Cholangiopancreatography in Bilioenteric Anastomosis: Eun Taek Park; Clin Endosc 2016;49(6):510-514. Published online November 14, 2016; DOI: https://doi.org/10.5946/ce.2016.138

Abstract PDF PubReader ePub

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.

Citations

Citations to this article as recorded by

Asymptomatic bile duct stones: The devil is in the details
Mohammed Omar Khalifa Elsayed, Mohamed Gamal Talkhan
World Journal of Gastrointestinal Endoscopy.2024; 16(5): 227. CrossRef
Application of endoscopic retrograde cholangiopancreatography for treatment of obstructive jaundice after hepatoblastoma surgery: A case report
Jun Shu, Hu Yang, Jun Yang, Hong-Qiang Bian, Xin Wang
World Journal of Clinical Cases.2023; 11(11): 2502. CrossRef
Use of modified therapeutic upper endoscope for ERCP in patients post pancreaticoduodenectomy
Nicholas M. McDonald, Mohamed Abdallah, Dharma Sunjaya, Mohammad Bilal
Endoscopy International Open.2022; 10(06): E905. CrossRef
Experience of endoscopic retrograde cholangiopancreatography with side-viewing duodenoscope in patients with previous gastric surgery
Mehmet Emin Gürbüz, Dursun Özgür Karakaş
Turkish Journal of Surgery.2022; 38(2): 149. CrossRef
EUS-Guided Pancreatic Duct Puncture for Difficult Cannulation of Stenosed Pancreaticojejunostomy
Eugenia N. Uche-Anya, Christopher D. Packey, Ali S. Khan, Amrita Sethi
Digestive Diseases and Sciences.2018; 63(1): 268. CrossRef

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Case Report

Endoscopic Management of Afferent Loop Syndrome after a Pylorus Preserving Pancreatoduodenecotomy Presenting with Obstructive Jaundice and Ascending Cholangitis: Jae Kyung Kim, Chan Hyuk Park, Ji Hye Huh, Jeong Youp Park, Seung Woo Park, Si Young Song, Jaebock Chung, Seungmin Bang; Clin Endosc 2011;44(1):59-64. Published online September 30, 2011; DOI: https://doi.org/10.5946/ce.2011.44.1.59

Abstract PDF PubReader ePub

Afferent loop syndrome is a rare complication of gastrojejunostomy. Patients usually present with abdominal distention and bilious avomiting. Afferent loop syndrome in patients who have undergone a pylorus preserving pancreaticoduodenectomy can present with ascending cholangitis. This condition is related to a large volume of reflux through the biliary-enteric anastomosis and static materials with bacterial overgrowth in the afferent loop. Patients with afferent loop syndrome after pylorus preserving pancreaticoduodenectomy frequently cannot be confirmed as surgical candidates due to poor medical condition. In that situation, a non-surgical palliation should be considered. Herein, we report two patients with afferent loop syndrome presenting with obstructive jaundice and ascending cholangitis. The patients suffered from the recurrence of pancreatic cancer after pylorus preserving pancreaticoduodenectomy. The diagnosis of afferent loop syndrome was confirmed, and the patients were successfully treated by inserting an endoscopic metal stent using a colonoscopic endoscope.

Citations

Citations to this article as recorded by

Percutaneous transhepatic duodenal drainage is good option for afferent loop syndrome for obstructive colorectal cancer patient with history of Billroth's operation II: A case report of a rare postoperative complication
Tung‐Yuan Chen, Chin‐Wen Hsu, Yee‐Phoung Chang, Min‐Tsung Wang, Yueh‐Jung Wu, Ching‐Hsien Wang, Kuan‐Yu Wang, Tian‐Huei Chu, Yung‐Kuo Lee
Clinical Case Reports.2023;[Epub] CrossRef
An Unusual Presentation of Obstructive Jaundice Due to Dilated Proximal Small Bowel Loops After Gastrojejunostomy: Afferent Loop Syndrome
Mahrukh Ali, Om Parkash, Jehanzeb Shahid
Cureus.2022;[Epub] CrossRef
The Use of Palliative Endoscopic Ultrasound-guided Enterostomy to Treat Small Bowel Obstruction in Two Patients with Advanced Malignancies
Ji Hong Oh, Seung Goun Hong
The Korean Journal of Medicine.2022; 97(3): 191. CrossRef
Endoscopic Transluminal Stent Placement for Malignant Afferent Loop Obstruction
Chinatsu Yonekura, Takashi Sasaki, Takafumi Mie, Takeshi Okamoto, Tsuyoshi Takeda, Takaaki Furukawa, Yuto Yamada, Akiyoshi Kasuga, Masato Matsuyama, Masato Ozaka, Naoki Sasahira
Journal of Clinical Medicine.2022; 11(21): 6357. CrossRef
Clinical management for malignant afferent loop obstruction
Arata Sakai, Hideyuki Shiomi, Atsuhiro Masuda, Takashi Kobayashi, Yasutaka Yamada, Yuzo Kodama
World Journal of Gastrointestinal Oncology.2021; 13(7): 509. CrossRef
Clinical management for malignant afferent loop obstruction
Arata Sakai, Hideyuki Shiomi, Atsuhiro Masuda, Takashi Kobayashi, Yasutaka Yamada, Yuzo Kodama
World Journal of Gastrointestinal Oncology.2021; 13(7): 684. CrossRef
Endoscopic Self-Expandable Metal Stent Placement for Malignant Afferent Loop Obstruction After Pancreaticoduodenectomy: A Case Series and Review
Arata Sakai, Hideyuki Shiomi, Takao Iemoto, Ryota Nakano, Takuya Ikegawa, Takashi Kobayashi, Atsuhiro Masuda, Yuzo Kodama
Clinical Endoscopy.2020; 53(4): 491. CrossRef
Endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction after radical gastrectomy for gastric cancer
Yuning Cao, Xiangheng Kong, Daogui Yang, Senlin Li
Medicine.2019; 98(28): e16475. CrossRef
Comparative analysis of afferent loop obstruction between laparoscopic and open approach in pancreaticoduodenectomy
Ki Byung Song, Daegwang Yoo, Dae Wook Hwang, Jae Hoon Lee, Jaewoo Kwon, Sarang Hong, Jong Woo Lee, Woo Young Youn, Kyungyeon Hwang, Song Cheol Kim
Journal of Hepato-Biliary-Pancreatic Sciences.2019; 26(10): 459. CrossRef
Metal Stent Placement in the Afferent Loop Obstructed by Peritoneal Metastases—Experience of Five Cases
Yoshihide Kanno, Tetsuya Ohira, Yoshihiro Harada, Yoshiki Koike, Taku Yamagata, Megumi Tanaka, Tomohiro Shimada, Kei Ito
Clinical Endoscopy.2018; 51(3): 299. CrossRef
Colangitis por obstrucción de asa aferente tras duodenopancreatectomía cefálica
José Ruiz Pardo, Erik Llàcer-Millán, Pilar Jimeno Griñó, Juan Ángel Fernández Hernández, Pascual Parrilla Paricio
Cirugía Española.2016; 94(2): 106. CrossRef
Cholangitis Due to Afferent Loop Obstruction After Cephalic Duodenopancreatectomy
José Ruiz Pardo, Erik Llàcer-Millán, Pilar Jimeno Griñó, Juan Ángel Fernández Hernández, Pascual Parrilla Paricio
Cirugía Española (English Edition).2016; 94(2): 106. CrossRef
An unusual cause of simultaneous common bile and pancreatic duct dilation
Puneet Chhabra, Surinder Singh Rana, Vishal Sharma, Ravi Sharma, Rajesh Gupta, Deepak Kumar Bhasin
Gastroenterology Report.2015; 3(3): 258. CrossRef
A Case of Afferent Loop Syndrome Treated by Endoscopic Metal Stent Insertion Using Two Endoscopes
Jun Jae Kim, Young Koog Cheon, Tae Yoon Lee, Chan Sup Shim
The Korean Journal of Medicine.2015; 89(4): 428. CrossRef
Acute afferent loop syndrome in the early postoperative period following pancreaticoduodenectomy
H Nageswaran, A Belgaumkar, R Kumar, A Riga, N Menezes, T Worthington, ND Karanjia
The Annals of The Royal College of Surgeons of England.2015; 97(5): 349. CrossRef
Recurrent Cholangitis by Biliary Stasis Due to Non-Obstructive Afferent Loop Syndrome After Pylorus-Preserving Pancreatoduodenectomy: Report of a Case
Yukihiro Sanada, Naoya Yamada, Masanobu Taguchi, Kazue Morishima, Naoya Kasahara, Yuji Kaneda, Atsushi Miki, Yasunao Ishiguro, Akira Kurogochi, Kazuhiro Endo, Masaru Koizumi, Hideki Sasanuma, Takehito Fujiwara, Yasunaru Sakuma, Atsushi Shimizu, Masanobu H
International Surgery.2014; 99(4): 426. CrossRef
A Case of Gastrojejunostomy under Endoscopic Ultrasound Guidance for the Treatment of Jejunal Stenosis Induced by Cholangiocarcinoma Recurrence after Pancreaticoduodenectomy
Chikashi WATASE, Junzo SHIMIZU, Masahiro MURAKAMI, Yong Kong KIM, Shoki MIKATA, Junichi HASEGAWA
Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association).2014; 75(8): 2307. CrossRef
Electrohydraulic Lithotripsy of an Impacted Enterolith Causing Acute Afferent Loop Syndrome
Young Sin Cho, Tae Hoon Lee, Soon Oh Hwang, Sunhyo Lee, Yunho Jung, Il-Kwun Chung, Sang-Heum Park, Sun-Joo Kim
Clinical Endoscopy.2014; 47(4): 367. CrossRef

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A Case of Successful Embolization with Superselection by Endoscopic Hemoclipping for Pseudoaneurysmal Bleeding in a Patient with Pylorus Preserving Pancreaticoduodenectomy: Yong Hun Kim, M.D., Chang-Il Kwon, M.D., Sae Kyung Joo, M.D., Won Hee Kim, M.D., Hong Gern Bin, M.D., Man Deuk Kim, M.D. and Seong Gyu Hwang, M.D.; Korean J Gastrointest Endosc 2010;41(1):31-35. Published online July 31, 2010

Abstract PDF: Arterial bleeding after pancreaticoduodenectomy is a very serious complication with high mortality. Therefore, early diagnosis and treatment is essential. In particular, early detection and immediate embolization can be effectively used for the delayed massive bleeding that occurs from a pseudoaneurysmal rupture. However, sometimes intermittent bleeding or a vessel spasm can cause the bleeding focus to remain unidentified in spite of repeated angiography. We experienced a case of successful embolization with superselection by endoscopic hemoclipping in a patient who underwent pylorus preserving pancreaticoduodenectomy, and the patient's bleeding focus was not found after repeated angiography. Endoscopic hemoclip application can be useful for localizing a pseudoaneurysmal rupture in patients with pancreaticoduodenectomy. (Korean J Gastrointest Endosc 2010;41:31-35)

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종양과의 감별이 어려웠던 원위부 총담관의 감돈 결석 ( An Impacted Distal Common Bile Duct Stone Mimicking a Tumor : An Unusual Manifestation of Gallstone Disease ): Korean J Gastrointest Endosc 2001;22(6):449-453. Published online November 30, 2000

Abstract PDF: Patients with bile duct stones usually present with biliary pain, obstructive jaundice, ascending cholangitis, or pancreatitis, When endoscopic retrograde cholangiopancreatography (ERCP) is performed, bile duct stones are usually movable and thus easily detected. If a stone in the bile duct presents unusually, it may pose some diagnostic challenges. Recently, we experienced a case of an impacted distal common bile duct (CBD) stone mimicking a tumor which resulted in performing a pylorus-preserving pancreaticoduodenectomy in an asymptomatic 56-year-old man. On ERCP, an obstructing distal CBD lesion did not move even by doing brush cytology. Moreover, the result of brush cytology was positive for atypical cells. A major resective surgery performed after recovery from severe post-ERCP pancreatitis confirmed the diagnosis. Interestingly, this stone caused erosion with acute and chronic inflammation and fibrosis containing foci of mild epithelial dysplasia. We herein report an unusual manifestation of gallstone disease with a review of the literature. (Korean J Gastrointest Endosc 2001;22:449-453)

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