Endoscopic ultrasound-guided pancreaticogastrostomy reconstruction.

creaticogastrostomy anastomosis some− times occurs after surgical pancreatic re− section and pancreaticogastrostomy, re− sulting in abdominal pain and aggrava− tion of diabetes as a result of ductal hypertension [1]. Endoscopic ultrasound− (EUS−)guided pancreaticogastrostomy has been reported as a method for reduc− ing ductal hypertension in patients with chronic pancreatitis. We report a patient who underwent EUS−guided reconstruc− tion of a pancreaticogastrostomy with gastropancreatic stent placement, which rapidly improved his symptoms [2, 3]. A 65−year−old man who had a branch duct type of intrapapillary mucinous neo− plasm (IPMN) (l" Figure 1) underwent a duodenum−preserving pancreatic head resection and pancreaticogastrostomy anastomosis. Forty−five days later, he de− veloped a pancreatic pseudocyst (l" Fig− ure 2), which was drained under EUS gui− dance. Although computed tomography 6 months later showed that the pseudocyst had disappeared, the scan showed dilata− tion of the main pancreatic duct (l" Fig− ure 3). Decompression of the pancreatic duct was required to relieve his abdomi− nal pain and reduce his hyperglycemia. Because the main pancreatic duct could not be drained by endoscopic retrograde pancreatography, EUS−guided pancreati− cogastrostomy reconstruction was per− formed. An echo endoscope (GF−UC240 P−AL5; Olympus, Tokyo, Japan) was intro− duced into the stomach, and a 19−gauge needle (Echo−Tip; Wilson−Cook, Win− ston−Salem, North Carolina, USA) was used to puncture the main pancreatic duct and create a gastropancreatic fistula. We initially attempted to pass a 0.035− inch guide wire (Microvasive Endoscopy, Boston Scientific Corporation, Natick, Massachusetts, USA) through the stenotic anastomosis, but the guide wire could not be passed through the anastomosis (l" Figure 4). A 6−Fr (Soehendra Biliary Dilation Catheters, Wilson−Cook, Win− ston−Salem, North Carolina, USA) dilator was advanced over the guide wire to di− late the gastropancreatic fistula, and then a 5−Fr, 5−cm−long pancreatic stent (Geenen Pancreatic Stent Set, Wilson− Cook, Winston−Salem, North Carolina, USA) was advanced over the wire and through the gastropancreatic fistula. The stent was placed in the pancreatic duct with the tip positioned in the proximal duct (l" Figure 5, l" Figure 6). The pa− tient’s abdominal pain was rapidly re− lieved and his hyperglycemia had im− proved 1 month later.