Endoscopic ultrasound-guided choledochojejunostomy with a forward-viewing echoendoscope for severe benign bilioenteric stricture in a patient with Child’s resection

Anastomotic strictures occurring after choledochojejunostomy have generally been treated by a percutaneous approach. A recent study reported that good outcomes were obtained after balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography [1]. A number of procedures have been reported to be useful, including endoscopic ultrasound (EUS)-guided hepaticojejunostomy combined with antegrade stent placement [2], EUS-guided trans-hepatic antegrade balloon dilation [3], and EUS-guided choledochojejunostomy [4].

We describe our experience with a patient in whom we directly inserted a forward-viewing echoendoscope (TGF-UC260J; Olympus, Tokyo, Japan) [5], which punctured the bile duct at a hepaticojejunal anastomotic site. We then successfully placed a metal stent in retrograde fashion.

The patient was a 74-year-old man with pancreatic cancer who had undergone pylorus-preserving pancreaticoduodenectomy and a modified Child’s resection. However, a stricture developed 11 months after surgery. Retrograde stent placement with a single-balloon enteroscope and antegrade stent placement with a percutaneous cholangioscope failed because a guidewire could not pass through the stricture. A cholangiogram obtained during percutaneous trans-hepatic biliary drainage (PTBD) showed that the anastomotic site was completely occluded ([Fig. 1]).

Fig. 1 A cholangiogram obtained during percutaneous trans-hepatic biliary drainage in a patient with an anastomotic stricture after choledochojejunostomy shows that the anastomotic site is completely occluded.

A forward-viewing echoendoscope reached the hepaticojejunal anastomosis in 17 minutes. The bile duct was confirmed through an anastomotic stricture measuring about 10 mm and was punctured with a 19-gauge needle ([Fig. 2]). A guidewire was then placed ([Video 1]). Subsequently, the anastomotic site was dilated with a 6-Fr diathermic dilator, and a 4-cm partially covered metal stent was placed in 35 minutes ([Video 2]). There were no procedural complications. The left and right bile ducts were confirmed to be free of occlusion on PTBD cholangiography ([Fig. 3]). The patient was discharged 2 days after treatment.

Fig. 2 a The hepaticojejunal anastomosis. There is no evidence of bile leakage. b A forward-viewing echoendoscope reaches the hepaticojejunal anastomosis. c A 10-mm stricture, the bile duct, and the percutaneous biliary drainage (PTBD) tube as viewed from the anastomotic site. d The bile duct is punctured with a 19-gauge needle.

A forward-viewing echoendoscope reaches the site of the hepaticojejunal anastomosis, and the bile duct is punctured via the anastomotic site (the jejunum).

After cholangiography, the anastomotic site is dilated with the use of a diathermic dilator, and a metal stent is placed.

Fig. 3 The endoscopic ultrasound-guided choledochojejunostomy on the next day. a Dilation of the metal stent is confirmed. b The right and left bile ducts are confirmed to be free of occlusion.

Our results confirm that EUS-guided choledochojejunostomy performed with a forward-viewing echoendoscope is a new treatment option for patients with severe bilioenteric strictures.

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• References

• 1 Sakakihara I, Kato H, Muro S et al. Double-balloon enteroscopy for choledochojejunal anastomotic stenosis after hepato-biliary-pancreatic operation. Dig Endosc 2015; 27: 146-154
• 2 Ogura T, Edogawa S, Imoto A et al. EUS-guided hepaticojejunostomy combined with antegrade stent placement. Gastrointest Endosc 2015; 81: 462-463
• 3 Park do H, Jang JW, Lee SS et al. EUS-guided transhepatic antegrade balloon dilation for benign bilioenteric anastomotic strictures in a patient with hepaticojejunostomy. Gastrointest Endosc 2012; 75: 692-693
• 4 Itoi T, Ikeuchi N, Tonozuka R et al. EUS-guided choledochojejunostomy with a lumen-apposing metal stent in a post-Whipple patient. Gastrointest Endosc Epub 2014 Oct 14
• 5 Kida M, Araki M, Miyazawa S et al. Fine needle aspiration using forward-viewing endoscopic ultrasonography. Endoscopy 2011; 43: 796-801