Endoscopy 2018; 50(07): E146-E148
DOI: 10.1055/a-0591-2109
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© Georg Thieme Verlag KG Stuttgart · New York

Rendezvous biliary recanalization with combined percutaneous transhepatic cholangioscopy and double-balloon endoscopy

Hiroshi Kawakami
Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
,
Tesshin Ban
Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
,
Yoshimasa Kubota
Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
,
Shinya Ashizuka
Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
,
Ichiro Sannomiya
Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
,
Naoya Imamura
Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
,
Takeomi Hamada
Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
› Author Affiliations
Further Information

Corresponding author

Hiroshi Kawakami, MD, PhD
Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital
5200, Kiyotake, Kihara
Miyazaki 889-1692
Japan   
Fax: +81-985-859802   

Publication History

Publication Date:
13 April 2018 (eFirst)

 

Despite advances in biliary stenting in patients with altered gastrointestinal anatomy, it is still a challenging procedure [1]. We present a case where percutaneous transhepatic cholangioscopy (PTCS) was combined with double-balloon endoscopy (DBE) for biliary stenting in a patient with complete obstruction of a choledochojejunostomy.

A 71-year-old woman, who had a history of distal cholangiocarcinoma and had undergone pancreaticoduodenectomy 7 years previously, experienced recurrent cholangitis. DBE-assisted balloon dilation had been performed 7 months previously for stricture of the choledochojejunal anastomosis. However, she developed complete obstruction of the anastomosis ([Fig. 1]). A 7.2-Fr percutaneous transhepatic biliary drainage (PTBD) catheter was initially placed, and the fistula tract was dilated up to 12 Fr within 4 weeks. DBE-assisted endoscopic retrograde cholangiopancreatography was then attempted. First, the double-balloon endoscope (EI-580BT; Fujifilm, Tokyo, Japan) was advanced to the afferent limb, and a percutaneous transhepatic cholangiogram revealed complete obstruction of the anastomosis. Next, a PTCS scope (BF type P260F; Olympus, Tokyo, Japan) was inserted via the PTBD route. However, a guidewire (0.018-inch, Pathfinder Exchange; Boston Scientific Japan, Tokyo, Japan) through the PTCS scope could not pass the anastomosis ([Video 1]). Therefore, we attempted direct precutting (KD-V451M; Olympus) at the anastomosis, using the double-balloon endoscope and guided by transillumination from the percutaneous transhepatic cholangioscope’ ([Fig. 2], [Video 1]). A small incision was carefully made in order to create a fistula ([Fig. 3]). This was followed by successful passage of the guidewire (0.032-inch, Radifocus Guidewire M; Terumo, Tokyo, Japan) completely through the anastomotic obstruction ([Fig. 4], [Video 1]). We then grasped the guidewire with an ultraslim basket catheter (Zero Tip Retrieval Basket; Boston Scientific) using the cholangioscope ([Fig. 5], [Video 1]). Finally, a 12-Fr PTBD catheter was placed across the obstruction without any complications ([Fig. 6], [Video 1]).

Zoom Image
Fig. 1 Percutaneous transhepatic cholangiogram showing complete obstruction of the choledochojejunal anastomosis in a patient who had undergone pancreaticoduodenectomy 7 years previously.

Video 1 Biliary recanalization, using a rendezvous technique with combined percutaneous transhepatic cholangioscopy and double-balloon endoscopy, for a completely obstructed choledochojejunostomy.

Georg Thieme Verlag. Please enable Java Script to watch the video.
Zoom Image
Fig. 2 Left panel: The choledochojejunal anastomosis has an appearance similar to an ulcer scar. Right panel: Transillumination from the percutaneous transhepatic cholangioscope guides direct precutting using the double-balloon endoscope.
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Fig. 3 Radiograph showing direct precutting at the choledochojejunal anastomosis, under fluoroscopic guidance and transillumination from the percutaneous transhepatic cholangioscope. Left inset: enteroscopy view. Right inset: percutaneous transhepatic cholangioscopy view.
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Fig. 4 Radiograph showing the guidewire passing through the obstruction. Inset: percutaneous transhepatic cholangioscopy view.
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Fig. 5 The guidewire is grasped by means of a snare under fluoroscopic and percutaneous transhepatic cholangioscopic guidance.
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Fig. 6 Insertion of the percutaneous transhepatic biliary drainage catheter, using a rendezvous technique, across the previously obstructed choledochojejunal anastomosis. Inset: percutaneous transhepatic cholangioscopic view.

The rendezvous technique in combination with PTCS and DBE facilitates biliary recanalization of complete biliary obstruction [1] [2]. However, blind incision has the risk of gastrointestinal tract perforation or bile leakage. Although caution should be exercised, incision guided by transillumination from the peroral transhepatic cholangioscope is a safe and less invasive technique compared with surgery.

Endoscopy_UCTN_Code_TTT_1AR_2AJ

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Competing interests

None


Corresponding author

Hiroshi Kawakami, MD, PhD
Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital
5200, Kiyotake, Kihara
Miyazaki 889-1692
Japan   
Fax: +81-985-859802   


Zoom Image
Fig. 1 Percutaneous transhepatic cholangiogram showing complete obstruction of the choledochojejunal anastomosis in a patient who had undergone pancreaticoduodenectomy 7 years previously.
Zoom Image
Fig. 2 Left panel: The choledochojejunal anastomosis has an appearance similar to an ulcer scar. Right panel: Transillumination from the percutaneous transhepatic cholangioscope guides direct precutting using the double-balloon endoscope.
Zoom Image
Fig. 3 Radiograph showing direct precutting at the choledochojejunal anastomosis, under fluoroscopic guidance and transillumination from the percutaneous transhepatic cholangioscope. Left inset: enteroscopy view. Right inset: percutaneous transhepatic cholangioscopy view.
Zoom Image
Fig. 4 Radiograph showing the guidewire passing through the obstruction. Inset: percutaneous transhepatic cholangioscopy view.
Zoom Image
Fig. 5 The guidewire is grasped by means of a snare under fluoroscopic and percutaneous transhepatic cholangioscopic guidance.
Zoom Image
Fig. 6 Insertion of the percutaneous transhepatic biliary drainage catheter, using a rendezvous technique, across the previously obstructed choledochojejunal anastomosis. Inset: percutaneous transhepatic cholangioscopic view.