Subscribe to RSS
Endoscopic ultrasound-guided duodenojejunostomy for management of refractory benign hepaticojejunal anastomotic stricture
09 May 2019 (online)
A 45-year-old man was referred to our endoscopy unit because of a benign refractory hepaticojejunal anastomotic stricture. Previous transhepatic anastomotic dilations had failed to guarantee long-term patency. We proposed endoscopic ultrasound (EUS)-guided duodenojejunostomy created using a lumen-apposing metal stent (LAMS) to allow endoscopic management of the bilioenteric stricture.
The efferent limb was filled with water and contrast medium from the percutaneous biliary transhepatic drainage (PTBD) ([Fig. 1 a, b]). Then under EUS guidance, a LAMS (Hot-Axios, 10 × 15 mm) was deployed from the duodenal bulb into the target jejunal loop, using pure cut effect 4. A long 0.025-inch guidewire was coiled inside the loop. Under fluoroscopic and endoscopic guidance both flanges of the LAMS were successfully deployed without complications ([Video 1]).
Video 1 Endoscopic ultrasound (EUS)-guided duodenojejunostomy created using a lumen-apposing metal stent (LAMS) to enable endoscopic management of a bilioenteric anastomotic stricture. The duodenojejunostomy allowed delivery of a fully covered self-expandable metal stent (FCSEMS) across the stricture in the same session.
In the same session, a fully covered self-expandable metal stent (FCSEMS) (Wallflex; Boston Scientific) was deployed across the stenosed bilioenteric anastomosis ([Fig. 2]).
The patient started on an oral diet the same day and he was discharged on day 1. At 6-month follow-up, upper endoscopy was performed with easy passage through the LAMS to remove the FCSEMS. Subsequent evaluation highlighted a good patency of the anastomosis with no secondary biliary stones ([Video 1]).
At 9 months after the EUS-guided duodenojejunostomy and 3 months from FCSEMS removal the patient is asymptomatic with normal liver test results. The LAMS is still in place.
Benign stricture may occur in up to 24 % of cases after bilioenteric anastomosis , and PTBD is the gold standard treatment. EUS-guided anastomosis using a LAMS is becoming standardized in tertiary centers, for cholecystogastrostomy, gastrojejunal anastomosis, and in cases of altered anatomy  .
We report one of the first cases of EUS-guided duodenojejunostomy where a prior PTBD was used to fill the target jejunal loop with water and contrast medium.
Direct EUS-guided transgastric hepatic injection in order to fill the jejunal loop is another viable option that would allow a single-operator single-session procedure.
Permanent duodenojejunostomy using a LAMS seems a feasible and safe technique for the management, of bilioenteric anastomotic stricture in selected cases.
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
- 1 Dimou FM, Adhikari D, Mehta HB. et al. Incidence of hepaticojejunostomy stricture after hepaticojejunostomy. Surgery 2016; 160: 691-698
- 2 Jacques J, Privat J, Pinard F. et al. Endoscopic ultrasound-guided choledochoduodenostomy with electrocautery-enhanced lumen-apposing stents: a retrospective analysis. Endoscopy 2018; DOI: 10.1055/a-0735-9137. [Epub ahead of print]
- 3 Jain D, Chhoda A, Sharma A. et al. De-novo gastrointestinal anastomosis with lumen apposing metal stent. Clin Endosc 2018; 51: 439-449