Technical tips for antegrade endopancreatic radiofrequency ablation for severe pancreatojejunal stricture

Pancreatojejunal stricture (PJS) is one of the late adverse events after pancreatoduodenectomy, and can lead to pancreatitis or endocrine pancreatic insufficiency as complications 1. PJS is usually treated under enteroscopic guidance 2, although, because of the relatively low technical success rate and prolonged procedure time, an endoscopic ultrasound (EUS)-guided transluminal approach has recently been developed for pancreatic disease 3. However, in cases of severe PJS, guidewire passage through the PJS into the intestine under the EUS-guided approach might be challenging, since the PJS site cannot be directly visualized. To overcome this issue, a technique involving antegrade transluminal pancreatoscope insertion has been developed. However, despite successful guidewire passage, PJS dilation might still be challenging because the pushing force might be lower in the EUS-guided approach than the enteroscopic approach. Although electrocautery dilation is a useful technique 4, recurrence of PJS is possible since the burning effect is small. On the other hand, endobiliary radiofrequency ablation (RFA) can sufficiently burn fibrotic tissue 5. We herein describe a novel technique for PJS treatment using RFA with a pancreatoscope.