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CC BY 4.0 · Endoscopy 2024; 56(S 01): E25-E26
DOI: 10.1055/a-2218-2260
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Endoscopic ultrasound-guided transduodenal ERCP for hepatico-jejunostomy stricture

Jun Liang Teh
1   Department of Surgery, Chinese University of Hong Kong, Hong Kong, Hong Kong
,
Shannon M Chan 
2   Department of Surgery, Chinese University of Hong Kong, Hong Kong, Hong Kong
,
Hon Chi Yip 
2   Department of Surgery, Chinese University of Hong Kong, Hong Kong, Hong Kong
,
Anthony Yuen Bun Teoh 
1   Department of Surgery, Chinese University of Hong Kong, Hong Kong, Hong Kong
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A 75-year-old man was referred for management of a hepaticojejunostomy (HJS) stricture following HJS performed for a bile duct injury during cholecystectomy 3 months prior. A short-type double-balloon enteroscopy (DBE) was attempted but was unsuccessful due to inability to reach the HJS. Endoscopic ultrasound (EUS)-guided transduodenal endoscopic retrograde cholangiopancreatography (ERCP) for management of the HJS stricture was planned [1].

An EUS-guided duodenum–afferent limb bypass was first performed with a lumen-apposing metal stent (LAMS) between the duodenum and the afferent limb ([Video 1]). On EUS, the afferent limb was identified from the duodenum and punctured with a 19G needle (EZshot 3; Olympus Medical, Tokyo, Japan) ([Fig. 1]).The afferent limb was distended by infusion of 500 ml of normal saline mixed with indigo-carmine and contrast medium. Over a 0.025-inch guidewire, the delivery system of the cautery-enhanced LAMS delivery system (Hanarostent Z-EUS IT; M.I. Tech, Gyeonggi-do, South Korea) was inserted and a 16 × 20-mm stent was deployed into the afferent limb ([Fig. 2], [Fig. 3]) [2]. ERCP was subsequently performed after 3 days with a dual-channel endoscope inserted into the afferent limb via the LAMS. The HJS ([Fig. 4]) was dilated with a 6-mm biliary balloon (Hurricane Biliary RX; Boston Scientific, Marlborough, Massachusetts, USA). Two plastic stents were inserted into bilateral intrahepatic ducts.


Quality:
Cannulation of the afferent limb via the lumen-apposing metal stent (white arrow) deployed between the duodenum and afferent limb bypass. Dilatation of the stenosed hepaticojejunostomy orifice was performed with a 6-mm biliary balloon.Video 1

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Fig. 1 Identification of the afferent limb and puncture of the afferent limb with a 19G FNA needle.
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Fig. 2 Deployment of the distal flange of the lumen-apposing metal stent (LAMS). The LAMS was pulled back before deployment in the channel and full deployment under endoscopic guidance.
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Fig. 3 Endoscopic view of the fully deployed LAMS between the duodenum and the afferent limb.
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Fig. 4 Identification of the stenosed hepatico-jejunostomy orifice (white arrow) in the afferent limb.

The patient was discharged on post-procedure day 2. No other complications or unplanned procedure occurred on follow-up. The patient underwent stent exchange at 6 months. No residual stricture was evident on cholangiogram at 9 months post-procedure. The HJS stricture occurs in up to 12.5% of patients at 2 years post hepatico-jejunostomy [3]. In this patient with an HJS stricture after Roux-en-Y HJS, EUS-guided duodenum–afferent limb bypass was successful for access to the HJS for ERCP after failed DBE-assisted ERCP.

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Publication History

Article published online:
09 January 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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  • References

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