Long-standing enteroenteric anastomosis with lumen-apposing metal stents to access bilioenteric anastomotic strictures: yes we can!

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with post-surgical altered upper gastrointestinal anatomy has been challenging since the early days of the technique. Until recent years, before the advent of proton pump inhibitors and the recognition of Helicobacter pylori as the etiologic factor of peptic ulcers, the vast majority of patients with altered gastrointestinal anatomy requiring an ERCP had undergone a partial gastrectomy with gastrojejunal anastomosis, commonly known as Billroth II gastrectomy. In these patients, the hurdles of ERCP were to progress with the endoscope into the afferent loop and reach the duodenal stump (especially when using a side-viewing duodenoscope), and then to cannulate the papilla in a reverse position. Performing the sphincterotomy was also a problem, and several different techniques to overcome the difficulties related to the upside-down position of the papilla were described [1].

This scenario has substantially changed today, mainly because of the dissemination of those bariatric surgical procedures that interrupt the gastroduodenal continuity, such as Roux-en-Y gastric bypass. In these patients the papilla is reachable only with device (overtube)-assisted enteroscopes (single-balloon, double-balloon, spiral); the success rate in reaching the duodenum with these endoscopes is around 80 %, but ERCP success rate goes down to 70 % [2]. This is due to several limitations of the technique: forward-viewing scopes, operative channel of limited size, and scarcity of dedicated accessories. Other common settings that can impair ERCP procedures are previous pancreaticoduodenectomy and Roux-en-Y hepaticojejunostomy. Device-assisted enteroscopy has widely been used in these settings too, with the same limitations cited above. Furthermore, this technique is time-consuming and needs a special endoscopic expertise to be accomplished. For these reasons, as an alternative to the endoscopic approach, percutaneous transhepatic access to the biliary tree is still very popular in these settings. However, percutaneous access also has several limitations: higher risk of adverse events [3], discomfort for the patient (especially if percutaneous drains are to be left for long periods of time, when repeated interventions are planned because of anastomotic strictures), and risk of displacement of the percutaneous drains.

“This technique not only provides a significant improvement in the management of bilioenteric anastomotic strictures in patients with altered upper gastrointestinal anatomy, but it appears to be able to offer a long-standing and safe approach for endoscopic re-treatment of recurrent strictures, which are not uncommon in this setting.”

A permanent potential access to the jejunal limb for repeated biliary percutaneous interventions, after hepaticojejunostomy, may be established by fixing under the skin the blind extremity of the limb, which can then be easily punctured under radiologic control. Several series utilizing this technique have been published [4], including the use of a cholangioscope via this route. More recently, another alternative endoscopic method to manage benign biliary strictures in patients with altered anatomy, in order to avoid the percutaneous approach, has been described. This involves the creation of a hepaticogastrostomy under endoscopic ultrasound guidance with placement of a fully covered self-expandable metal stent connecting the gastric lumen to the left intrahepatic biliary system. After an adequate time frame (4 to 6 weeks) to allow consolidation of the track, multiple interventions on the anastomotic site are possible, such as balloon dilation, stone retrieval, stent placement, and cholangioscopy [5]. The advantages of this technique are, on the one side, the avoidance of the long-term complications associated with the percutaneous access and of the discomfort related to the long-standing external drains, and on the other side, an easy and repeatable access to the bile ducts for iterative treatments, which are frequently required to treat benign strictures of biliodigestive anastomoses.

With the same intent of avoiding the disadvantages of a long-standing percutaneous approach and to maintain access to the biliodigestive anastomotic stricture, Mutignani et al. had the brilliant idea of creating an endoscopic ultrasound-guided duodenojejunal anastomosis with the help of a lumen-apposing metal stent (LAMS), which allows for direct visualization of the anastomotic site with a duodenoscope or a gastroscope [6]. After this first case report, the same group reported on a series of 32 cases of endoscopic enteroenteral bypass with a success rate of 97 % and a very limited number of early and late adverse events. This technique allowed the management of biliodigestive anastomotic strictures with different tools, mainly fully covered metal stents. In this experience, LAMS were left “in situ” for 1 year on average, without major adverse events, allowing repeated interventions for recurrent problems at medium-term follow-up [7]. The same approach has been recently validated in a multicenter experience reporting on 18 cases, with a clinical success rate of more than 94 % and without major adverse events [8]. Eight of the 17 LAMS were successfully removed at the end of treatment, but the authors do not give details on the timing of removal. Actually, the issue of potential complications of long-standing LAMS is still not clarified.

In this issue of Endoscopy, Donatelli et al. [9] add an important insight to elucidate this concern. They report on a series of 11 patients undergoing duodenojejunal or jejunojejunal anastomosis with LAMS (success rate 10 /11), which, when successful, allowed access to the bilioenteric anastomosis in all cases. LAMS were kept in place to permit endoscopic reinterventions in case of recurrent strictures (40 % of the cases, on average after 16 months from the index treatment). All LAMS were still in place after more than 2 years on average, without any adverse event. This technique not only provides a significant improvement in the management of bilioenteric anastomotic strictures in patients with altered upper GI anatomy, but it appears to be able to offer a long-standing and safe approach for endoscopic re-treatment of recurrent strictures, which are not uncommon in this setting.

Publication History

Article published online:
25 February 2021

• References

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