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Endoscopic pancreatic stenting using the combination technique of injection needle and needle knife for complete pancreaticojejunal anastomotic obstruction

A 69‐YEAR‐OLD WOMAN who underwent pancreaticoduodenectomy presented with chronic diarrhea and exacerbation of diabetes mellitus. Magnetic resonance cholangiopancreatography revealed dilatation of the main pancreatic duct (MPD) (Fig. 1a). Exocrine and endocrine pancreatic insufficiency due to pancreaticojejunal anastomotic stenosis (PJS) were considered as possible causes of the symptoms. Therefore, endoscopic retrograde pancreatography (ERP) was planned. On endoscope (PCFH290ZI; Olympus Medical Systems, Tokyo, Japan) insertion, the anastomotic site (AS), which was characterized by membranous obstruction, was identified (Fig. 2a). ERP using a conventional cannulation method was considered difficult because of complete anastomotic obstruction (CAO). As we confirmed that there were no major blood vessels around the AS on computed tomography (Fig. 1b), ERP using an injection needle (23-G TOP endoscopic injection needle; TOP, Tokyo, Japan) was performed. Four punctures were required for ERP and dilatation of the MPD was observed (Fig. 2b). The AS was incised using a needle knife (KD-1L-1; Olympus Medical Systems) (Fig. 2c). After incision of the AS and guidewire placement, it was dilated using a dilator (ES dilator; Zeon Medical, Tokyo, Japan) and a 5-Fr 9 5-cm pancreatic stent (Advanix Pancreatic Stent; Boston Scientific Japan, Tokyo, Japan) was placed without adverse events (Fig. 2d) (Video S1). For CAO in PJS, endoscopic ultrasound-guided pancreatic duct drainage is preferred because endoscopic pancreatic stenting under ERP (EPS) is technically challenging. However,EPShas the advantage that it canbe safely performedusing a physiological route. Similar to our technique, for CAO in hepaticojejunostomy, cholangiography and guidewire placement were simultaneously performed through a 20-G injection needle, and the access route to the bile duct was secured using a