Endoscopy 2021; 53(10): E380-E381
DOI: 10.1055/a-1304-3304
E-Videos

Percutaneous-endoscopic rendezvous via cap-assisted adult colonoscope to deal with biliary and multiple intestine strictures after total gastrectomy

Zhenghong Li
Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
,
Weiming Dai
Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
,
Lijuan Yang
Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
,
Rong Wan
Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
,
Xiaobo Cai
Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
› Author Affiliations
 

A 68-year-old man was admitted with vomiting and jaundice. He had undergone total gastrectomy and Roux-en-Y jejunojejunostomy for cardiac cancer a year earlier. Magnetic resonance imaging indicated abdominal tumor metastasis and dilatation of the intrahepatic bile ducts.

A cap-assisted adult colonoscope was used for endoscopic biliary drainage owing to abnormal anatomy. A jejunal stenosis was found near the esophagojejunostomy and a 1.5-cm-diameter balloon was applied to dilate the stricture ([Fig. 1]). The colonoscope then passed through the stenosis into the duodenum. However, the papilla could not be reached because of the duodenal stricture and cannulation was not performed ([Fig. 2]). Vomiting was not relieved after endoscopic dilation and a 22-mm-diameter uncovered metal stent was inserted ([Fig. 3]). After 2 days, a guidewire was percutaneously inserted into the intrahepatic bile duct and on to the intestine through the papilla under X-ray guidance. The cap-assisted adult colonoscope entered the afferent limb and the guidewire was grasped by a biopsy forceps and pulled out through the endoscopy channel. Cholangiography indicated significant stricture of the common bile duct ([Fig. 4]). A self-expandable metal stent, 8 mm in diameter and 10 cm in length was endoscopically inserted into the bile duct across the biliary and duodenal stricture, which also allowed further endoscopic interventions when needed ([Fig. 5]). A nasobiliary tube was placed within the bile duct for better biliary drainage and the guidewire was then removed ([Video 1]). The patient’s symptoms resolved and he was discharged after 1 week.

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Fig. 1 Jejunal stricture, causing vomiting, near the esophagojejunostomy.
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Fig. 2 The papilla could not be reached by the cap-assisted adult colonoscope because of the duodenal stricture, which was confirmed after injection of contrast agent.
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Fig. 3 An intestinal metal stent, 22 mm in diameter and 8 cm in length, was placed across the jejunal stricture.
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Fig. 4 Cholangiography indicated significant stricture of the common bile duct.
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Fig. 5 A metal stent, 8 mm in diameter and 10 cm in length was endoscopically inserted into the bile duct across the biliary and duodenal stricture.

Video 1 Percutaneous-endoscopic rendezvous via cap-assisted adult colonoscope for endoscopic retrograde cholangiopancreatography after total gastrectomy.


Quality:

Balloon-assisted enteroscopy is commonly applied for endoscopic retrograde cholangiopancreatography (ERCP) in patients with total gastrectomy and Roux-en-Y jejunojejunostomy [1]. However, special instruments and small-caliber endoscope channel limit its application [2]. In this novel approach, we applied an adult colonoscope with cap to perform ERCP, and percutaneous rendezvous was useful when the papilla could not be reached.

Endoscopy_UCTN_Code_TTT_1AP_2AD

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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Xiaobo Cai, MD
Department of Gastroenterology
Shanghai General Hospital
School of Medicine
Shanghai Jiaotong University
Haining Road 100
Shanghai 200080
China   
Fax: +86-21-63240090   

Publication History

Publication Date:
03 December 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Jejunal stricture, causing vomiting, near the esophagojejunostomy.
Zoom Image
Fig. 2 The papilla could not be reached by the cap-assisted adult colonoscope because of the duodenal stricture, which was confirmed after injection of contrast agent.
Zoom Image
Fig. 3 An intestinal metal stent, 22 mm in diameter and 8 cm in length, was placed across the jejunal stricture.
Zoom Image
Fig. 4 Cholangiography indicated significant stricture of the common bile duct.
Zoom Image
Fig. 5 A metal stent, 8 mm in diameter and 10 cm in length was endoscopically inserted into the bile duct across the biliary and duodenal stricture.