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HOME > Clin Endosc > Volume 58(2); 2025 > Article
Editorial Transforming endoscopic approaches to post-pancreaticoduodenectomy anastomotic strictures: beyond the surface
Yu-Ting Kuo1,2orcid
Clinical Endoscopy 2025;58(2):259-260.
DOI: https://doi.org/10.5946/ce.2025.004
Published online: March 24, 2025

1Division of Endoscopy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan

2Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan

Correspondence: Yu-Ting Kuo Division of Endoscopy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, National Taiwan University College of Medicine. No. 7, Chung-Shan South Road, Taipei 100, Taiwan E-mail: sfstruck@gmail.com
• Received: January 6, 2025   • Revised: January 29, 2025   • Accepted: January 30, 2025

© 2025 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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See the article "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" on page 311.
Pancreaticoduodenectomy (PD) is a well-established surgical treatment for tumors and other disorders of the pancreas, bile duct, and duodenum. However, pancreaticojejunal anastomotic stricture (PJAS) is a frequent late complication that can significantly impact quality of life due to recurrent obstructive pancreatitis and exocrine pancreatic dysfunction.1
For managing PJAS, endoscopic drainage is widely regarded as the first-line approach, providing a less invasive alternative to surgical decompression. Endoscopic retrograde pancreatography (ERP) traditionally involves endoscopy to locate the main pancreatic duct (MPD) orifice within the jejunal wall, followed by MPD cannulation. However, outcomes with ERP, particularly those assisted by standard endoscopes or enteroscopes, have often been limited, with reported clinical success rates frequently falling below 20%.2 A notable challenge in ERP is the small size of the pancreaticojejunostomy anastomosis, which often renders it undetectable, especially in cases of severe or complete obstruction. In such situations, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) serves as a valuable salvage method when ERP fails, offering higher rates of technical and clinical success.3
In 2002, the first use of an electronic oblique-viewing curved linear-array echoendoscope for transgastric EUS-guided pancreaticogastrostomy (EUS-PGS) was reported.4 Over the past two decades, significant advances have been made in EUS-PDD, but standardized EUS-PDD procedures have not yet been established. In general, EUS-PDD techniques can be categorized into two main anastomotic pancreatic drainage approaches: EUS-guided drainage/anastomosis (EUS-D/A) and EUS-guided rendezvous technique (EUS-RV).5 For patients with surgically altered anatomy, EUS-D/A can be further classified into EUS-PGS, EUS-guided pancreatojejunostomy (EUS-PJS), and EUS-guided pancreatoduodenostomy, depending on the approach. Current guidelines recommend EUS-PGS in cases where the papilla or anastomosis is inaccessible or when EUS-RV has failed.6 Despite its advantages, EUS-PGS remains technically challenging and carries a higher morbidity rate than other therapeutic EUS procedures. Complications include pancreatic fluid leakage and a need for frequent stent exchange via the stomach, both of which can significantly affect a patient’s quality of life.
In this issue of Clinical Endoscopy, Sadek et al.7 present the first retrospective analysis of the long-term outcomes of EUS-PJS using a forward-viewing curvilinear echoendoscope (FV-CLS), following 10 patients with PJAS after PD. Their findings reveal 100% technical and clinical success rates for EUS-PJS, with no significant early or late adverse events. During the median follow-up period of 9.5 months, none of the patients exhibited symptoms of MPD obstruction. FV-CLS is an advanced endoscopic technique that combines standard forward-viewing endoscopy with high-resolution ultrasound imaging of the organs and lesions within or adjacent to the gastrointestinal tract. Its forward-viewing design facilitates easier navigation through the gastrointestinal tract, making it particularly beneficial for patients with surgically altered anatomy and for accessing challenging anatomical sites. FV-CLS also enables vertical puncture within the gastrointestinal tract, thereby improving puncture accuracy and performance. The first reported case of EUS-PJS using FV-CLS via the afferent loop was performed by Nakaji et al. in 2015.8 Since then, this technique has been documented in case reports and case series with short-term follow-up periods.9,10 This approach provides a more straightforward and safer alternative, as it reaches the anastomosis site without traversing the abdominal cavity. Unlike transgastric EUS-PGS, EUS-PJS appears to be an effective and safe option for managing PJAS after PD, offering potential advantages including fewer reinterventions and the formation of a permanent drainage fistula. Although this study concluded that the FV-CLS insertion is both feasible and safe, the technique can be challenging if the afferent jejunal loop is long and twisted. In such cases, scope insertion may be facilitated using the “ropeway method”, where a stiff guidewire, pre-positioned by an enteroscope, helps straighten the twisted afferent loop. Given the lack of a control group in this study, further prospective randomized comparative clinical trials are warranted to confirm the superiority of EUS-PJS over transgastric EUS-PDD.
  • 1. Zarzavadjian Le Bian A, Cesaretti M, Tabchouri N, et al. Late pancreatic anastomosis stricture following pancreaticoduodenectomy: a systematic review. J Gastrointest Surg 2018;22:2021–2028.ArticlePubMedPDF
  • 2. Basiliya K, Veldhuijzen G, Gerges C, et al. Endoscopic retrograde pancreatography-guided versus endoscopic ultrasound-guided technique for pancreatic duct cannulation in patients with pancreaticojejunostomy stenosis: a systematic literature review. Endoscopy 2021;53:266–276.ArticlePubMed
  • 3. Chen 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;85:170–177.ArticlePubMed
  • 4. François E, Kahaleh M, Giovannini M, et al. EUS-guided pancreaticogastrostomy. Gastrointest Endosc 2002;56:128–133.ArticlePubMed
  • 5. Tomishima K, Isayama H, Suzuki A, et al. Technical review of endoscopic ultrasound-guided drainage/anastomosis and trans-endosonographically created route procedures for the treatment of pancreatic diseases. DEN Open 2024;5:e393.ArticlePubMedPMC
  • 6. van der Merwe SW, van Wanrooij RL, Bronswijk M, et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022;54:185–205.ArticlePubMed
  • 7. Sadek A, Hara K, Okuno N, et al. 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. Clin Endosc 2025;58:311–319.ArticlePubMed
  • 8. Nakaji S, Hirata N, Shiratori T, et al. Endoscopic ultrasound-guided pancreaticojejunostomy with a forward-viewing echoendoscope as a treatment for stenotic pancreaticojejunal anastomosis. Endoscopy 2015;47 Suppl 1 UCTN:E41–E42.ArticlePubMed
  • 9. Iwai T, Kida M, Yamauchi H, et al. EUS-guided transanastomotic drainage for severe biliopancreatic anastomotic stricture using a forward-viewing echoendoscope in patients with surgically altered anatomy. Endosc Ultrasound 2021;10:33–38.ArticlePubMedPMC
  • 10. Shimizu H, Suzuki R, Sato Y, et al. Transjejunal endoscopic ultrasound-guided pancreatic drainage for pancreatic jejunostomy stricture using a forward-viewing echoendoscope in a patient with altered anatomy. DEN Open 2022;2:e114.ArticlePubMedPMCPDF

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        Transforming endoscopic approaches to post-pancreaticoduodenectomy anastomotic strictures: beyond the surface
        Clin Endosc. 2025;58(2):259-260.   Published online March 24, 2025
        DOI: https://doi.org/10.5946/ce.2025.004
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