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CC BY-NC-ND 4.0 · Endoscopy 2023; 55(S 01): E696-E697
DOI: 10.1055/a-2058-8461
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Gel immersion radial incision and cutting for pancreaticojejunostomy anastomotic stricture

Nozomi Okuno 
Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
,
Kazuo Hara 
Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
,
Shin Haba 
Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
,
Takamichi Kuwahara 
Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
,
Yasuhiro Kuraishi
Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
,
Takafumi Yanaidani
Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
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Pancreaticojejunostomy anastomotic stricture (PJAS) is a late adverse event after pancreaticoduodenectomy [1] that can lead to pancreatic stones, pancreatitis, and abdominal pain. Radial incision and cutting (RIC) has shown promising results for esophagogastric stricture [2], and its usefulness for refractory PJAS was reported in 2021 [3]. However, there have been only a few cases, and the procedure remains challenging. The advantages of gel immersion endoscopy using a clear gel (VISCOCLEAR; Otsuka Pharmaceutical Factory) have been reported for securing a good visual field, including in endoscopic submucosal dissection [4]. Here, we report a case of PJAS treated by RIC during gel immersion endoscopy.

A woman in her 70s developed PJAS with pancreatic stones following pancreaticoduodenectomy for intraductal papillary mucinous neoplasm. A colonoscope (CH-HQ290ZI; Olympus) was inserted to the afferent loop and endoscopy revealed extreme scarring. Spraying with indigo carmine confirmed the presence of a pinhole PJAS ([Fig. 1]). After guidewire insertion, we dilated the severe stenosis using a spiral drill dilator (Tornus ES for 0.025 inch; Asahi Intecc). Balloon dilation (6 mm REN; Kaneka Medical Products) was performed but as a notch remained despite expansion to 8 atm, gel immersion RIC was attempted ([Video 1]). The gel secured a good visual field, and the air supply was turned off during radial incision and cutting. An ITknife2 (KD-611L; Olympus) was inserted into the stricture and the scar was incised in Endocut mode. Because the anastomosis was wide open using RIC, it was easy to remove the pancreatic stones ([Fig. 2]). Finally, a 7-Fr 5-cm plastic stent was placed and the gel was removed by suction. No adverse events were observed. RIC under gel immersion appears to be a safe and efficient procedure that can eliminate the need for an air supply, prevent an increase in pancreatic duct pressure, and prevent pancreatitis.

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Fig. 1 a Endoscopy shows extremely severe scarring at a pancreaticojejunostomy anastomotic stricture with pancreatic stones following pancreaticoduodenectomy for intraductal papillary mucinous neoplasm. b After spraying with indigo carmine, a pinhole pancreaticojejunostomy anastomotic stricture was confirmed. c A notch remained following balloon dilation.
Zoom Image
Fig. 2 a View from gel immersion endoscopy before radial incision and cutting. A good field of view was obtained without an air supply. b Endoscopy shows improvement of the stricture, and the pancreatic stones were easily removed.

Video 1 Gel immersion radial incision and cutting (RIC) is safe and efficient for the treatment of pancreaticojejunostomy anastomotic stricture (PJAS).


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Publication History

Article published online:
04 May 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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