Pancreatic duct drainage using EUS-guided rendezvous technique for stenotic pancreaticojejunostomy

The patient was a 30-year-old female who had undergone excision of the extrahepatic bile duct and Rouxen-Y hepaticojejunostomy for congenital biliary dilatation at the age of 7.Thereafter,she suffered from recurrent acute pancreatitis due to pancreaticobiliary maljunction and received subtotal stomach-preserving pancreaticoduodenectomy.She developed a pancreatic fistula and an intra-abdominal abscess after the operation.These complications were improved by percutaneous abscess drainage and antibiotic therapy.How ever,upper abdominal discomfort and the elevation of serum pancreatic enzymes persisted due to stenosis from the pancreaticojejunostomy.Because we could not accomplish dilation of the stenosis by endoscopic retrograde cholangiopancreatography,we tried an endoscopic ultrasonography(EUS) guided rendezvous technique for pancreatic duct drainage.After transgastric puncture of the pancreatic duct using an EUS-fine needle aspiration needle,the guidewire was inserted into the pancreatic duct and finally reached to the jejunum through the stenotic anastomosis.We changed the echoendoscope to an oblique-viewing endoscope,then grasped the guidewire and withdrew it through the scope.The stenosis of the pancreaticojejunostomy was dilated up to 4 mm,and a pancreatic stent was put in place.Though the pancreatic stent was removed after three months,the patient remained symptomfree.Pancreatic duct drainage using an EUS-guided rendezvous technique was useful for the treatment of a stenotic pancreaticojejunostomy after pancreaticoduodenectomy.

IgG4-unrelated type 1 autoimmune pancreatitis

A 50-year-old male was referred to our hospital for the evaluation of hyperproteinemia.Fluorodeoxyglucose positron emission tomography revealed high fluorodeoxyglucose uptake in the pancreas,bilateral lacrimal glands,submandibular glands,parotid glands,bilateral pulmonary hilar lymph nodes,and kidneys.Laboratory data showed an elevation of hepatobiliary enzymes,renal dysfunction,and remarkably high immunoglobulin(Ig) G levels,without elevated serum IgG4.Abdominal computed tomography revealed swelling of the pancreatic head and bilateral kidneys.Endoscopic retrograde cholangiopancreatography showed an irregular narrowing of the main pancreatic duct in the pancreatic head and stricture of the lower common bile duct.Histological examination by endoscopic ultrasonography-guided fine-needle aspiration revealed findings of lymphoplasmacytic sclerosing pancreatitis without IgG4-positive plasma cells.Abnormal laboratory values and the swelling of several organs were improved by the treatment with steroids.The patient was diagnosed as having type 1 autoimmune pancreatitis(AIP) based on the International Consensus Diagnostic Criteria.Therefore,we encountered a case of compatible type 1 AIP without elevated levels of serum IgG4 or IgG4-positive plasma cells.This case suggests that AIP phenotypes are not always associated with IgG4.