Anastomotic stenosis of the hepaticojejunostomy is a major complication following
pancreaticoduodenectomy [1]. In cases of complete anastomotic obstruction, drainage has been attempted using
a cholangioscope via the percutaneous transhepatic biliary drainage route or a forward-viewing
echoendoscope [2]
[3]. However, reports of direct puncture of the anastomotic site remain scarce [4]. Here, we present a case of complete hepaticojejunostomy obstruction successfully
managed with direct needle puncture drainage using a radial miniature probe (UM-2R;
Olympus, Tokyo, Japan).
A 72-year-old woman was under postoperative surveillance following surgery for pancreatic
tail cancer when an iatrogenic recurrence of pancreatic head cancer was detected.
She subsequently underwent residual pancreatectomy. Postoperatively, she developed
obstructive jaundice ([Fig. 1] and [Fig. 2]) and was referred to our department. Single-balloon enteroscopy (SIF-H290S; Olympus,
Tokyo, Japan) was performed to evaluate the hepaticojejunostomy anastomosis; however,
complete occlusion precluded biliary drainage. The endoscope was then switched to
a therapeutic video gastroscope (GIF-H290T; Olympus, Tokyo, Japan) to access the anastomotic
site. Water was slowly injected through the auxiliary water channel, and the water-filled
area surrounding the hepaticojejunostomy was visualized using the UM-2R. The right
hepatic artery and portal vein were clearly identified, confirming a safe trajectory
for puncturing the anastomosis and accessing the bile duct.
Fig. 1 Arterial phase of contrast-enhanced computed tomography. a Dilatation of the intrahepatic duct upstream of the hepaticojejunostomy anastomosis.
b No tumor recurrence was noted near the hepaticojejunostomy anastomosis. The right
hepatic artery and portal vein are adjacent to the anastomosis.
Fig. 2
a–b T2-weighted image (a) and magnetic resonance cholangiopancreatography (b) showing intrahepatic duct dilation.
A 19-G needle was used to directly puncture the hepaticojejunostomy anastomosis, allowing
successful cholangiography. Following guidewire placement, the anastomotic stenosis
was dilated with a biliary balloon catheter, and 7-Fr biliary stents were placed in
the right and left hepatic ducts, achieving effective drainage ([Video 1]).
A 72-year-old woman with anastomotic stenosis of hepaticojejunostomy underwent dilatation
with a biliary balloon catheter. The right hepatic artery and portal vein were identified,
and the direction of puncture from the anastomosis to the bile duct was confirmed
to be safe Subsequently, 7-Fr biliary stents were placed in the right and left hepatic
ducts, achieving effective drainage.Video 1
Direct needle puncture of the hepaticojejunostomy anastomosis carries potential risks,
including small intestinal perforation, bile leakage, and vascular injury leading
to hemorrhage. However, the use of the UM-2R enabled safe bile duct access and drainage
while mitigating complications, thus broadening the scope of endoscopic management
for anastomotic stenosis.
Endoscopy_UCTN_Code_TTT_1AS_2AH
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