Endoscopy 2019; 51(12): E400-E401
DOI: 10.1055/a-0965-6402
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Lumen-apposing metal stent for the creation of an endoscopic duodenojejunostomy to facilitate bile duct clearance following Roux-en-Y hepaticojejunostomy

Olaya I. Brewer Gutierrez
Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
,
Thomas Runge
Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
,
Yervant Ichkhanian
Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
,
Kia Vosoughi
Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
,
Mouen A. Khashab
Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
› Author Affiliations
Further Information

Corresponding author

Mouen A. Khashab, MD
Johns Hopkins Hospital
Sheikh Zayed Bldg
Division of Gastroenterology and Hepatology
1800 Orleans Street, Suite 7125G
Baltimore, MD 21287
USA   
Fax: +1-443-683-8335   

Publication History

Publication Date:
24 July 2019 (online)

 

    A 52-year-old woman with history of bile duct injury following cholecystectomy and previous Roux-en-Y hepaticojejunostomy was admitted because of cholangitis. Her work-up revealed a 7-mm stone in the right intrahepatic duct on magnetic resonance cholangiopancreatography (MRCP). An initial single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) revealed independent right and left hepaticojejunostomies and bilateral strictures. A large right intrahepatic filling defect was identified on an occlusion cholangiogram ([Fig. 1]). Bilateral dilation of the anastomosis was performed with an 8-mm hydrostatic balloon, but the stone could not be removed and two plastic biliary stents (7 F × 5 cm) were placed.

    Zoom Image
    Fig. 1 Occlusion cholangiogram during enteroscopy-assisted endoscopic retrograde cholangiopancreatography showing a large right intrahepatic filling defect.

    Contrast injection into the biliopancreatic limb showed that it was closely approximated to the duodenal bulb and therefore suitable for an endoscopic ultrasound (EUS)-guided duodenojejunostomy (EUS-DJ) to facilitate access to the afferent limb and complete clearance of the bile duct using the appropriate accessories. A single-balloon enteroscope fitted with a cap was advanced to the hepaticojejunostomy. The afferent limb was filled with diluted contrast mixed with 1 % methylene blue, and 2 mg of glucagon was given intravenously to slow peristalsis. A linear echoendoscope was then advanced to the duodenal bulb and the distended jejunal limb was identified and punctured using a 19-gauge fine-needle aspiration (FNA) needle. Aspiration of blue-tinged fluid confirmed the correct location in the afferent limb. A cautery-enhanced lumen-apposing metal stent (LAMS; 15 mm × 10 mm) was deployed, thereby creating a duodenojejunostomy ([Video 1]).

    Video 1 Endoscopic ultrasound-guided duodenojejunostomy in a patient with a Roux-en-Y hepaticojejunostomy and right intrahepatic duct stone.


    Quality:

    The patient returned 4 weeks after the procedure for an ERCP with cholangioscopy. A therapeutic upper gastrointestinal endoscope was advanced to the duodenojejunostomy ([Fig. 2 a]) and the hepaticojejunostomy was identified 1 – 2 cm distally ([Fig. 2 b]). A digital single-operator cholangioscope was advanced into the right anterior, mid, and posterior branches of the right intrahepatic duct. Sludge but no stones were seen in the posterior branch ([Fig. 3]). The left intrahepatic duct was normal. The patient underwent a further MRCP and a follow-up ERCP after 4 weeks with no additional stones identified ([Fig. 4]), and the LAMS was removed. To date, the patient has remained asymptomatic.

    Zoom Image
    Fig. 2 Endoscopic views showing: a the patent duodenojejunostomy lumen-apposing metal stent; b the independent right/left hepaticojejunostomy.
    Zoom Image
    Fig. 3 Digital cholangioscopic view showing no evidence of persisting intraductal stones.
    Zoom Image
    Fig. 4 Cholangiographic view during follow-up endoscopic retrograde cholangiopancreatography performed through the duodenojejunostomy. showing no residual right or left intrahepatic stones.

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    Competing interests

    Mouen A. Khashab is a consultant for Boston Scientific, Medtronic and Olympus.
    The remaining authors have no competing interests to disclose.


    Corresponding author

    Mouen A. Khashab, MD
    Johns Hopkins Hospital
    Sheikh Zayed Bldg
    Division of Gastroenterology and Hepatology
    1800 Orleans Street, Suite 7125G
    Baltimore, MD 21287
    USA   
    Fax: +1-443-683-8335   


    Zoom Image
    Fig. 1 Occlusion cholangiogram during enteroscopy-assisted endoscopic retrograde cholangiopancreatography showing a large right intrahepatic filling defect.
    Zoom Image
    Fig. 2 Endoscopic views showing: a the patent duodenojejunostomy lumen-apposing metal stent; b the independent right/left hepaticojejunostomy.
    Zoom Image
    Fig. 3 Digital cholangioscopic view showing no evidence of persisting intraductal stones.
    Zoom Image
    Fig. 4 Cholangiographic view during follow-up endoscopic retrograde cholangiopancreatography performed through the duodenojejunostomy. showing no residual right or left intrahepatic stones.