Endoscopy 2021; 53(05): E174-E176
DOI: 10.1055/a-1216-1220
E-Videos

Duckbill-type antireflux self-expandable metal stent placement for post-choledochojejunostomy reflux cholangitis

Takehiko Koga
1  Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Susumu Hijioka
1  Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Yasutake Ishikawa
2  Department of Radiological Technology, National Cancer Center Hospital, Tokyo, Japan
,
Kimiteru Ito
3  Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
,
Shota Harai
1  Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Takuji Okusaka
1  Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Yutaka Saito
4  Department of Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
› Author Affiliations
Supported by: This work was supported in part by The National Cancer Center Research and Development Fund (31-A-13).
 

Reflux cholangitis is a common complication of choledochojejunostomy [1] [2]. Intestinal content reflux is considered a possible cause for this complication when there is no stenosis at the choledochojejunal anastomosis [3] [4] [5], and post-choledochojejunostomy reflex cholangitis (PCRC) is not an indication for endoscopic procedures (e. g., stenting). Here, we discuss using antireflux self-expandable metal stents (ARMS) to treat a patient with PCRC.

A 43-year-old woman who 4.5 years earlier had undergone total pancreatectomy and choledochojejunostomy (Child reconstruction) for multiple pancreatic neuroendocrine tumors presented with fever caused by PCRC. She was treated with antibiotics and ursodeoxycholic acid. However, the fever recurred two or three times a week.

Computed tomography showed pneumobilia, and 99 mTc-N-pyridoxyl-5-methyltryptophan (99 mTc-PMT) hepatobiliary scintigraphy showed high tracer uptake in the afferent and blind loops. Endoscopy (CF-H260AI; Olympus Medical Systems, Tokyo, Japan) revealed that the choledochojejunal anastomosis was dilated with cholestasis. No bile duct stones were observed ([Fig. 1]).

Zoom Image
Fig. 1 Imaging findings before the procedure. a Computed tomography (CT) showing pneumobilia (arrows). b Single-position emission CT (SPECT)/CT 90 min after injection of 99 mTc-PMT tracer, showing high tracer uptake in the afferent loop (arrow) and blind loop (arrowhead). c, d Endoscopic images showing the choledochojejunal anastomosis markedly dilated (arrows) with cholestasis (arrowheads).

We speculated that PCRC was caused by cholestasis in the anastomosis and planned for ARMS placement. Cholangiography showed that the common hepatic duct was 23 mm in diameter; side-by-side placement of two 10-mm ARMS was considered ideal.

A 7-Fr plastic stent (Harmo Ray; Hanaco Medical, Saitama, Japan) was inserted into B6 to prevent the posterior branch from being obstructed by the ARMS. Two duckbill-type ARMS (D-ARMS; 10 mm × 6 cm; Kawasumi Laboratories, Tokyo, Japan; [Fig. 2]) were placed in the anterior branch and the left hepatic duct, respectively, using the side-by-side method. To prevent stent migration, the D-ARMS were fixed to the jejunal mucosa using clips (SureClip; Micro-Tech Endoscopy, Ann Arbor, Michigan, USA) ([Fig. 3], [Fig. 4]; [Video 1]).

Zoom Image
Fig. 2 Duckbill-type antireflux self-expandable metal stent (D-ARMS).
Zoom Image
Fig. 3 Fluoroscopic images of two D-ARMS with plastic stent placement. a Cholangiography with balloon catheter. The guidewire was inserted into B6 (arrow). b A 7-Fr plastic stent was placed in B6. c The first D-ARMS was placed in the anterior branch. d The second D-ARMS was placed in the left hepatic duct using the side-by-side method.
Zoom Image
Fig. 4 Imaging findings after the procedure. a, b Endoscopic images of two D-ARMS on the anastomosis. c The D-ARMS was fixed to the jejunal mucosa using a clip (arrowhead). d Fluoroscopic image after the procedure.

Video 1 D-ARMS placement in a patient with refractory post-choledochojejunostomy reflux cholangitis.


Quality:

Hepatobiliary scintigraphy showed that cholestasis was notably reduced in the afferent and blind loops after the procedure, and the patient’s fever had improved ([Fig. 5]).

Zoom Image
Fig. 5 Body temperature chart and SPECT/CT images before and after the endoscopic procedure. a Body temperature chart. After the procedure, the fever disappeared completely. b, c Three-dimensional SPECT/CT images (90 min after injection of tracer) before (b) and after the procedure (c). After the procedure, cholestasis was notably reduced in the afferent and blind loops.

This is the first report discussing D-ARMS placement in PCRC. Dramatic improvement of symptoms was observed, demonstrating that D-ARMS can serve as a new treatment for PCRC.

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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Susumu Hijioka, MD, PhD
Department of Hepatobiliary and Pancreatic Oncology
National Cancer Center Hospital
5-1-1 Tsukiji, Chuo-ku
Tokyo 104-0045
Japan   
Fax: +81-3-35423815   

Publication History

Publication Date:
20 August 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Imaging findings before the procedure. a Computed tomography (CT) showing pneumobilia (arrows). b Single-position emission CT (SPECT)/CT 90 min after injection of 99 mTc-PMT tracer, showing high tracer uptake in the afferent loop (arrow) and blind loop (arrowhead). c, d Endoscopic images showing the choledochojejunal anastomosis markedly dilated (arrows) with cholestasis (arrowheads).
Zoom Image
Fig. 2 Duckbill-type antireflux self-expandable metal stent (D-ARMS).
Zoom Image
Fig. 3 Fluoroscopic images of two D-ARMS with plastic stent placement. a Cholangiography with balloon catheter. The guidewire was inserted into B6 (arrow). b A 7-Fr plastic stent was placed in B6. c The first D-ARMS was placed in the anterior branch. d The second D-ARMS was placed in the left hepatic duct using the side-by-side method.
Zoom Image
Fig. 4 Imaging findings after the procedure. a, b Endoscopic images of two D-ARMS on the anastomosis. c The D-ARMS was fixed to the jejunal mucosa using a clip (arrowhead). d Fluoroscopic image after the procedure.
Zoom Image
Fig. 5 Body temperature chart and SPECT/CT images before and after the endoscopic procedure. a Body temperature chart. After the procedure, the fever disappeared completely. b, c Three-dimensional SPECT/CT images (90 min after injection of tracer) before (b) and after the procedure (c). After the procedure, cholestasis was notably reduced in the afferent and blind loops.