Postoperative benign biliary strictures are major adverse events following biliary
surgery. Endoscopic retrograde cholangiography (ERC) is the standard treatment, but
it is sometimes challenging in patients with surgically altered anatomy despite the
development of balloon enteroscopy [1]. Recently, endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) has
been reported as an effective salvage technique [2]
[3]. We report a case in which, after formation of an EUS-HGS fistula, re-intervention
and diagnosis of the cause of a stricture were easily performed using intraductal
cholangioscopy (IDC; SpyGlass DS system; Boston Scientific Corp., Natick, Massachusetts,
USA) through the hepaticogastrostomy route.
A 67-year-old man who previously underwent right hepatectomy for hilar cholangiocarcinoma
developed repeated episodes of cholangitis because of an anastomotic biliary stricture.
Because ERC using a double-balloon enteroscope failed, EUS-HGS was performed and a
fully covered metal stent was placed ([Fig. 1 a]). After the fistula had matured, brush cytology was attempted to identify the cause
of the stricture. The metal stent was removed, leaving the guidewire, and the brush
was inserted ([Fig. 1 b]; [Video 1]). A double-pigtail stent was then placed from the anastomotic stricture to the fistula.
The brush cytology showed an atypical cell that could not be distinguished as benign
or malignant.
Fig. 1 Radiographic images showing: a endoscopic ultrasound (EUS)-guided hepaticogastrostomy being performed and a fully
covered metal stent being placed; b brush cytology being performed through the hepaticogastrostomy route in an attempt
to identify the cause of the stricture; c the intraductal cholangioscope being inserted through the hepaticogastrostomy route.
Video 1: Brush cytology is performed through the hepaticogastrostomy route. The intraductal
cholangioscope is then inserted through the hepaticogastrostomy to obtain direct visualization
and to perform a biopsy using forceps. The intraductal cholangioscopy image shows
a benign stricture and a biopsy is successfully taken.
Brush cytology was then performed repeatedly; however, a diagnosis could still not
be made. Therefore, an intraductal cholangioscope was inserted through the hepaticogastrostomy
to obtain direct visualization and perform a biopsy using forceps under direct visualization
([Fig. 1 c]). The IDC image showed a benign stricture and the result of the biopsy showed no
evidence of malignancy ([Video 1]).
In the present case, EUS-HGS was performed successfully. The procedure time was short
and re-intervention was performed easily and safely using the hepaticogastrostomy
route. Because balloon enteroscopy is sometimes challenging, the present approach
could become one of the choices for patients with surgically altered anatomy who are
in need of re-intervention.
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