Forward-viewing echoendoscope is useful for recanalization of postoperative biliary anastomotic atresia in endosonography-guided biliary drainage

One possible cause of biliary peritonitis and stent migration as adverse events of transgastrohepatic endosonography-guided biliary drainage (EUS-BD) [1] is a puncture site in the stomach wall and liver that is not fixed. Magnetic compression anastomosis (MCA) is applied to fix two organs, the gastrointestinal tract and the bile duct [2] [3]. Herein, we present an alternative technique to fix these organs without MCA through recanalization of postoperative biliary anastomotic atresia with EUS-BD using a forward-viewing echoendoscope.

A 78-year-old man who underwent pancreatoduodenectomy because of cholangiocarcinoma was admitted with retrograde cholangitis. We tried to insert internal–external drainage tubes as percutaneous transhepatic biliary drainage tubes; however, the guidewire could not be inserted through the bile duct owing to complete atresia of the anastomosis site ([Fig. 1]).

Fig. 1 Endoscopic image showing complete atresia of the anastomosis site between the bile duct and jejunum, which was covered by jejunal mucosa.

We then performed EUS-BD with a forward-viewing echoendoscope (TGF-UC260 J, EU-ME1; Olympus Medical Systems, Tokyo, Japan) ([Fig. 2]; [Video 1]). We identified the anastomosis site by endoscopy and confirmed by endoscopic ultrasound that the guidewire that was inserted through a percutaneous transhepatic approach was in the bile duct. We punctured the bile duct at the anastomosis site with a puncture needle and placed the guidewire into the bile duct. Although we tried to dilate the bile duct with a balloon dilator, the device could not go through the needle tract. Therefore, the bile duct was dilated with a wire-guided diathermic dilator. We reinserted the balloon dilator and exchanged it initially for a plastic stent (QuickPlaceV; Olympus Medical Systems) ([Fig. 3]) and subsequently for a wide-caliber stent, before adding another stent to dilate the recanalization route ([Fig. 4]). No adverse events of EUS-BD were observed. One year after EUS-BD was performed, the patient was free from all stents ([Fig. 5]).

Fig. 2 Photograph of the forward-viewing echoendoscope (TGF-UC260 J, EU-ME1; Olympus Medical Systems, Tokyo, Japan).

Video 1 A forward-viewing echoendoscope can enable a more vertical approach to the anastomosis site and help establish a rigid connection between the jejunum and bile duct in endosonography-guided biliary drainage.

Fig. 3 Endoscopic image immediately following the exchange of a balloon dilator with a 7-Fr straight plastic stent with a length of 5 cm.

Fig. 4 Endoscopic image 5 months after endosonography-guided biliary drainage after the recanalization route had been dilated with 8.5-Fr and 7-Fr straight plastic stents with lengths of 5 cm.

Fig. 5 Endoscopic image 1 year after endosonography-guided biliary drainage showing the recanalization route that remained open after the patient was free from all stents.

A forward-viewing echoendoscope may allow us to approach the anastomosis site more vertically and shorten the puncture distance, contributing to the feasibility and safety of the procedure [4].

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• References

• 1 Mukai S, Itoi T, Sofuni A. et al. EUS-guided antegrade intervention for benign biliary diseases in patients with surgically altered anatomy (with videos). Gastrointest Endosc 2019; 89: 399-407
• 2 Matsuura R, Ueno T, Tazuke Y. et al. Magnetic compression anastomosis for postoperative biliary atresia. Pediatr Int 2017; 59: 737-739
• 3 Itoi T, Kasuya K, Sofuni A. et al. Magnetic compression anastomosis for biliary obstruction: review and experience at Tokyo Medical University Hospital. J Hepatobiliary Pancreat Sci 2011; 18: 357-365
• 4 Hara K, Yamao Y, Hijioka S. et al. Prospective clinical study of endoscopic ultrasound-guided choledochoduodenostomy with direct metallic stent placement using a forward-viewing echoendoscope. Endoscopy 2013; 45: 392-396