Antegrade metallic stent placement using a slim cholangioscope for malignant afferent loop obstruction

Enteral metallic stent placement using balloon enteroscopy is reported as a therapeutic strategy for malignant afferent loop obstruction [1] [2]; however, it is challenging when the enteroscope cannot reach the stricture. Metallic stent placement via endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is rarely reported in such difficult conditions [3] [4]. Here we report antegrade metallic stenting using a slim cholangioscope for malignant afferent loop obstruction ([Video 1]).

Antegrade metallic stent placement for malignant afferent loop obstruction was performed under guidance of a slim cholangioscope.Video 1

A 78-year-old man who underwent pancreaticoduodenectomy with Roux-en-Y reconstruction was referred to our hospital with a benign hepaticojejunostomy anastomotic stricture. EUS-HGS was performed because balloon enteroscopy could not reach the afferent loop ([Fig. 1]). The patient developed cholangitis 2 years later due to a malignant afferent loop obstruction with abdominal dissemination ([Fig. 2]). Enteral metallic stent placement was performed via the EUS-HGS route ([Fig. 3]). An endoscopic retrograde cholangiopancreatography catheter was inserted into the afferent loop; however, a guidewire could not pass through the stricture. A slim cholangioscope (9-Fr eyeMAX; Micro-Tech, Nanjing, China) was inserted into the afferent loop via the EUS-HGS and hepaticojejunostomy anastomoses. The guidewire was then successfully passed through the stricture using a cholangioscope. Contrast-enhanced imaging revealed a localized stricture in the afferent loop. After cholangioscope removal, a balloon dilation catheter was inserted; however, it could not pass through the stricture. A guide sheath (UMIDAS sheath cannula; UMIDAS Inc., Kanagawa, Japan) was inserted into the stricture and a biliary metallic stent with an ultraslim delivery system (YABUSAME Neo; KANEKA Medics, Tokyo, Japan) was successfully passed and placed through the guide sheath. Contrast agent flowed out through the metallic stent and the patient’s abdominal pain was relieved.

Fig. 1 Fluoroscopic images. a A single-balloon enteroscope could not reach into the afferent loop. b Endoscopic ultrasound-guided hepaticogastrostomy was performed for hepaticojejunostomy anastomotic stricture.

Fig. 2 Computed tomography showed a dilated afferent loop due to a malignant stricture.

Fig. 3 Fluoroscopic images. a An endoscopic retrograde cholangiopancreatography catheter was inserted into the afferent loop and the stricture was revealed. b The guidewire was passed through the stricture under guidance of the slim cholangioscope. c A metallic stent with ultraslim delivery was inserted through the guide sheath. d The stent was successfully placed, and the contrast agent flowed out.

To the best of our knowledge, this is the first report of antegrade metallic stent placement using cholangioscopy in a case of malignant afferent loop obstruction. This case demonstrates that a slim cholangioscope may aid guidewire placement in difficult conditions.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Sasaki T, Yamada I, Matsuyama M. et al. Enteral stent placement for malignant afferent loop obstruction by the through-the-scope technique using a short-type single-balloon enteroscope. Endosc Int Open 2018; 6: E806-E811
• 2 Sakai A, Shiomi H, Iemoto T. et al. Endoscopic self-expandable metal stent placement for malignant afferent loop obstruction after pancreaticoduodenectomy: a case series and review. Clin Endosc 2020; 53: 491-496
• 3 Ratone J-P, Caillol F, Bories E. et al. Hepatogastrostomy by EUS for malignant afferent loop obstruction after duodenopancreatectomy. Endosc Ultrasound 2015; 4: 250-252
• 4 Shimamoto Y, Maruyama H, Kurokawa T. et al. Endoscopic ultrasound-guided antegrade treatment with uncovered self-expanding metal stent for malignant afferent loop syndrome-complicated cholangitis after biliary reconstruction. Endoscopy 2024; 56: E478-E479

Publication History

Article published online:
04 September 2024