Endoscopic management of pancreatic diseases in patients with surgically altered anatomy: clinical outcomes of combination of double‐balloon endoscopy‐ and endoscopic ultrasound‐guided interventions

Objectives In patients with surgically altered anatomy, endoscopic treatment of pancreatic diseases is technically challenging. We aimed to evaluate the feasibility, effectiveness, and safety of an interchangeable combination of double‐balloon endoscope‐assisted ERP (DB‐ERP) and endoscopic ultrasonography‐guided pancreatic duct drainage (EUS‐PD) in this clinical setting. Methods Consecutive patients with surgically altered anatomy undergoing endoscopic treatment (DB‐ERP, EUS‐PD, or both) for pancreatic diseases were studied. The primary outcome was technical success; secondary outcomes were clinical success and adverse events. Results Forty patients who underwent DB‐ERP (38) and EUS‐PD (2) as an initial intervention were retrospectively studied. Indications for intervention included 18 pancreaticojejunostomy anastomotic stricture (PJAS), four pancreatic duct stone (PDS), four pancreatic fistula (PF), 11 PJAS with PDS, and three PJAS with PF. Prior surgical reconstruction was 26 Billroth‐II, 13 Roux‐en‐Y, and one Imanaga reconstruction. Along with salvage procedures including three DB‐ERP and seven EUS‐PD, the overall technical success rates of DB‐ERP and EUS‐PD were 70.7% (29/41) and 100% (9/9), respectively. Clinical success was achieved in 85.0% (34/40) by combination of DB‐ERP and EUS‐PD; successful drainage for PJAS, complete removal of PDS, and resolution of PF were achieved in 90.6%, 80.0%, and 71.4%, respectively. Adverse event rates were 12.2% (5/41; one perforation, and four pancreatitis) in DB‐ERP and 55.6% (5/9; three pancreatic leakage, and two abdominal pain) in EUS‐PD. Conclusions A combination of DB‐ERP and EUS‐PD can achieve high technical and clinical success for pancreatic diseases in surgically altered anatomy patients. A prospective multicenter study to investigate an appropriate treatment algorithm is warranted.