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.

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

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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