Percutaneous-endoscopic rendezvous via cap-assisted adult colonoscope to deal with biliary and multiple intestine strictures after total gastrectomy

A 68-year-old man was admitted with vomiting and jaundice. He had undergone total gastrectomy and Roux-en-Y jejunojejunostomy for cardiac cancer a year earlier. Magnetic resonance imaging indicated abdominal tumor metastasis and dilatation of the intrahepatic bile ducts.

A cap-assisted adult colonoscope was used for endoscopic biliary drainage owing to abnormal anatomy. A jejunal stenosis was found near the esophagojejunostomy and a 1.5-cm-diameter balloon was applied to dilate the stricture ([Fig. 1]). The colonoscope then passed through the stenosis into the duodenum. However, the papilla could not be reached because of the duodenal stricture and cannulation was not performed ([Fig. 2]). Vomiting was not relieved after endoscopic dilation and a 22-mm-diameter uncovered metal stent was inserted ([Fig. 3]). After 2 days, a guidewire was percutaneously inserted into the intrahepatic bile duct and on to the intestine through the papilla under X-ray guidance. The cap-assisted adult colonoscope entered the afferent limb and the guidewire was grasped by a biopsy forceps and pulled out through the endoscopy channel. Cholangiography indicated significant stricture of the common bile duct ([Fig. 4]). A self-expandable metal stent, 8 mm in diameter and 10 cm in length was endoscopically inserted into the bile duct across the biliary and duodenal stricture, which also allowed further endoscopic interventions when needed ([Fig. 5]). A nasobiliary tube was placed within the bile duct for better biliary drainage and the guidewire was then removed ([Video 1]). The patient’s symptoms resolved and he was discharged after 1 week.

Fig. 1 Jejunal stricture, causing vomiting, near the esophagojejunostomy.

Fig. 2 The papilla could not be reached by the cap-assisted adult colonoscope because of the duodenal stricture, which was confirmed after injection of contrast agent.

Fig. 3 An intestinal metal stent, 22 mm in diameter and 8 cm in length, was placed across the jejunal stricture.

Fig. 4 Cholangiography indicated significant stricture of the common bile duct.

Fig. 5 A metal stent, 8 mm in diameter and 10 cm in length was endoscopically inserted into the bile duct across the biliary and duodenal stricture.

Video 1 Percutaneous-endoscopic rendezvous via cap-assisted adult colonoscope for endoscopic retrograde cholangiopancreatography after total gastrectomy.

Balloon-assisted enteroscopy is commonly applied for endoscopic retrograde cholangiopancreatography (ERCP) in patients with total gastrectomy and Roux-en-Y jejunojejunostomy [1]. However, special instruments and small-caliber endoscope channel limit its application [2]. In this novel approach, we applied an adult colonoscope with cap to perform ERCP, and percutaneous rendezvous was useful when the papilla could not be reached.

Endoscopy_UCTN_Code_TTT_1AP_2AD

Publication History

Article published online:
03 December 2020

• References

• 1 Li K, Huang YH, Yao W. et al. Adult colonoscopy or single-balloon enteroscopy-assisted ERCP in long-limb surgical bypass patients. Clin Res Hepatol Gastroenterol 2014; 38: 513-519
• 2 Lopes TL, Baron TH. Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. J Hepatobiliary Pancreat Sci 2011; 18: 332-338