A 41-year-old woman who had undergone orthotopic liver transplantation (OLT) with
Roux-en-Y reconstruction for primary sclerosing cholangitis (PSC) presented with recurrent
cholangitis due to biliary cast syndrome. She had undergone a total of seven enteroscopy-assisted
endoscopic retrograde cholangiopancreatographies (ERCPs) at an outside tertiary institution
without successful clinical results. She was referred to our center for further management.
Magnetic resonance cholangiopancreatography (MRCP) revealed an extensive burden of
large intrahepatic stones ([Fig. 1 a]).
Fig. 1 Management of biliary cast syndrome in a patient who had undergone liver transplantation
with Roux-en-Y reconstruction. a Magnetic resonance cholangiopancreatography image showing multiple large intrahepatic
stones (arrows). b Fluoroscopic view of the gastrojejunostomy (GJ; large arrow) near the hepaticojejunostomy
(HJ; small arrow). c Endoscopic view of a deployed gastrojejunostomy lumen-apposing metal stent (LAMS).
d Fluoroscopic view of an endoscope passing through the LAMS (arrow). e Cholangioscopy-guided electrohydraulic lithotripsy (EHL) with the tip of the catheter
targeting a large intrahepatic stone. f Cholangioscopy view 8 weeks after EHL therapy of the stones showing complete right
intrahepatic duct clearance.
Recently, endoscopic ultrasonography (EUS)-guided creation of a gastroenteric anastomosis
has been described using a lumen-apposing metal stent (LAMS) for the management of
benign and malignant gastric outlet obstruction [1]
[2]. Creation of such an anastomosis may be beneficial in patients with complex surgical
upper gastrointestinal anatomy who present with challenging pancreaticobiliary pathologies.
The plan was to create an endoscopic gastrojejunostomy fistula using a LAMS close
to the hepaticojejunostomy to permit subsequent endoscopic management of biliary cast
syndrome with conventional ERCP and electrohydraulic lithotripsy (EHL).
The afferent limb was accessed with an enteroscope and was filled with a mixed solution
of saline, contrast, and methylene blue. The limb was easily localized with EUS transgastrically
and was then punctured with a 19 G needle, with aspiration of blue dye confirming
it was correctly placed. An EUS-guided gastrojejunostomy was created using the direct
technique and a 15-mm LAMS with electrocautery-enhanced delivery system (Axios; Boston
Scientific Massachusetts, USA) ([Fig. 1 b, c]).
A further ERCP was performed 4 weeks later, during which a standard therapeutic gastroscope
was advanced through the fistula and the stent into the hepaticojejunostomy ([Fig. 1 d]), which was few centimeters distal to the created endoscopic gastrojejunostomy.
A cholangiogram revealed dilated intrahepatic ducts with multiple small and large
filling defects consistent with intrahepatic stones. The digital single-operator cholangioscope
(Spyglass DS; Boston Scientific) was advanced over the guidewire into the intrahepatic
ducts. Multiple large stones were seen in the intrahepatic ducts. An EHL probe was
introduced through the working channel of the cholangioscope, with the tip positioned
directly at the stone ([Fig. 1 e]). The stones were fragmented into small pieces. The digital cholangioscope was advanced
into secondary and tertiary branches of the right intrahepatic duct under fluoroscopic
and cholangioscopic guidance. The right intrahepatic system was packed with large
stones. Large stones throughout the intrahepatic system were successfully fragmented
into small pieces to ensure passage through the small ducts. A plastic biliary stent
(7 Fr × 9 cm) was placed into the left intrahepatic duct and a fully covered self-expandable
metallic stent (8 mm × 60 mm; WallFlex, Boston Scientific) was placed in the right
intrahepatic duct to facilitate passage of the fragmented stones ([Video 1]).
Video 1 An endoscopic ultrasonography-guided gastrojejunostomy fistula created using a lumen-apposing
metal stent is used to permit subsequent endoscopic management with conventional endoscopic
retrograde cholangiopancreatography and electrohydraulic lithotripsy.
The patient developed mild post-procedural cholangitis, which was successfully treated
conservatively with antibiotics. An ERCP was performed again 8 weeks later. Contrast
injection and cholangioscopy confirmed no evidence of residual stones ([Fig. 1 f]).
EUS-guided alteration of complex surgical anatomy with the creation of an endoscopic
gastrojejunostomy is feasible and allows easy access to the bilio-enteric anastomosis.
This permits the use of standard ERCP equipment and, thus, performance of intricate
biliary interventions and management of challenging biliary pathologies, such as biliary
cast syndrome and difficult biliary stones.
Endoscopy_UCTN_Code_TTT_1AR_2AK
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
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freely accessible online.
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