HEPATICO-JEJUNOSTOMY´S ANASTOMOTIC STRICTURE TREATED BY ENTERAL-ENTERAL ENDOSCOPIC BYPASS GUIDED ERC: A TERTIARY REFERRAL SINGLE CENTER EXPERIENCE

Aims Since re-do surgery and interventional radiology are considered the first-line treatment for bilio-digestive anastomotic stricture, endoscopic treatment has been utilized as a minimally invasive alternative, with two critical issues: (1) ability to reach the biliary anastomosis; (2) perform an effective therapeutic procedure. We proposed a totally endoscopic approach to improve the endotherapy of bilio-digestive anastomotic stricture.

Methods From 01/2014 to 04/2019, 40 consecutive patients affected by bilio-digestive anastomotic stricture treated by endoscopic enteral-enteral bypass (EEEB) and subsequent endoscopic retrograde cholangiography (ERC) were included in the study.

Results Forthy consecutive patients (mean age 62 yo; M/F 26/14) underwent EEEB which was successful in all but two patients because of a perforation secondary to LAMS migration and an intraprocedural bleeding (technical success rate 95%). When EEEB is successfully performed, the therapeutical ERC’s rate was 100%, with the effective treatment of the anastomotic biliary stricture using large-bore fully covered metal stents (FC-SEMS). The most performed procedures were stone extraction and multiple metal stenting. During a mean follow-up of 2,5 years (3 mth- 5 y) we register a 100% clinical success (defined as resolution of presenting clinical problem) with a mean number of ERC sessions of 3. In two cases recurrent biliary stricture occurred, successfully re-treated through the EEEB (biliary strictures’ recurrence rate 5,3 %). Complications have been divided in short- and long-term depending on the onset < 48 or >48 hours from the procedures. We have no long-term complications.

Conclusions EEEB-guided ECR is safe, feasible, and effective in referral centers with high-level experience in both ERCP and EUS. It lets the use of endoscopes with large operative channel to treat the stenosis(es) with large-bore self-expandable metal stents, to manage case of complex strictures and multiple-ducts biliary anastomosis, to guarantee a long-lasting gradual dilation and to re-treat patients in case of recurrence.