Aims Stenosis of hepaticojejunostomy (HJ) is a potentially serious postoperative complication after pancreaticoduodenectomy (PD). It causes biliary stasis leading to intrahepatic lithiasis and recurrent cholangitis.
Methods We herein describe the case of a patient who underwent PD with Roux-en-Y reconstruction for an ampullary carcinoma six years earlier, developing late HJ stenosis.
Results The first episode of cholangitis was four years after surgery. After a trial of percutaneous transhepatic dilation and drainage (PTD), the episodes of cholangitis recurred.
A repeat Magnetic Resonance Cholangiography showed a permeable HJ and development of intrahepatic lithiasis. An Endoscopic Retrograde Cholangiopancreatography with double-balloon enteroscope was unsuccessful due to a slight twisting of the Roux-en Y anastomosis and the patient was placed with a percutaneous transanastomotic drain to prevent further episodes of cholangitis.
Because of the proximity of the pancreatic anastomosis to the HJ, a surgical approach was considered technically difficult and potentially hazardous. After multidisciplinary discussion, a Percutaneous Transhepatic Cholangioscopy was decided.
The procedure was performed with a dual-image system displaying the progression of the procedure with cholangiographic images alongside the cholangioscopic view, enabling the exact location of the cholangioscope inside the biliary tree.
However, since some debris remained even after copious lavage, a percutaneous transanastomotic drain was left in order to prevent cholangitis. This was removed a week later after repeat cholangiography confirmed clearance of the intrahepatic ducts and a permeable HJ. Six months after the procedure the patient is asymptomatic, with no clinical or biochemical signs of cholangitis or cholestasis.
Conclusions This innovative multidisciplinary approach ensured a clearance of the intrahepatic bile ducts, without morbidity or the need for reoperation, making it a therapeutic option in cases of intrahepatic stones and/or complex intrahepatic biliary pathology.
It is a new technique with enormous potential to grow but both worldwide experience and the literature on this topic is still scarce.
Citation
Correia C, Cardoso MJ, Almeida N et al. eP469 PERCUTANEOUS TRANSHEPATIC CHOLANGIOSCOPY - AN OPTION FOR THE TREATMENT OF INTRAHEPATIC LITHIASIS. Endoscopy 2021; 53: S251.
