This is the first report on the successful rendezvous technique of double-balloon
endoscopy (DBE) (EI-530B; Fujifilm, Osaka, Japan) combined with the percutaneous SpyGlass® direct visualization system (SDVS) (Boston Scientific Corp., Natick, MA, USA) to
treat severe stenosis of a choledochojejunal anastomosis in a patient with pancreaticoduodenectomy.
A 71-year-old man with a history of intraductal papillary mucinous neoplasm who had
undergone pylorus-preserving pancreaticoduodenectomy 6 months previously was admitted
for obstructive jaundice and acute cholangitis. He was referred for endoscopic retrograde
cholangiopancreatography (ERCP) using a “short” DBE for internalization of biliary
drainage. Locating the choledochojejunal anastomosis was difficult, but was successfully
achieved by detecting the ulcer-scar-like lesion and a little biliary flow in the
underwater observation ([Video 1 ]). However, the procedure failed because of a severe stenosis consisting of a long
stricture with a small orifice in the choledochojejunal anastomosis, which was denoted
a type A2 stricture in the classification of Mönkemüller and Jovanovic [1 ] and hindered the advancement of several devices. As an alternative, percutaneous
transhepatic cholangiodrainage (PTCD) was applied, but this was again precluded by
the severe stenosis. As the patient firmly refused to undergo further surgery, DBE-assisted
ERCP was reattempted. Indigo carmine was used to mark the location of the choledochojejunal
anastomosis and, using a needle knife (KD-V441M; Olympus Medical Systems, Tokyo, Japan),
the membranous anastomotic stenosis was incised ([Video 2 ]). When a blind incision was made in the presumed direction of the biliary duct,
the cholangiographic image showed leakage of contrast medium into the abdominal cavity
([Fig. 1 ]), indicating that the presumed orientation was incorrect. To assure the correct
direction of the incision, the SDVS was inserted via the PTCD route and successfully
functioned as a visible light guide, facilitating accurate incision into the biliary
duct ([Video 3 ]). Consequently, guidewires were advanced through the choledochojejunal anastomotic
stenosis and dilatation using an 8-mm dilator balloon (QBD-8X3; Cook Medical, Bloomington,
IN, USA) was successful, allowing placement of two endoscopic biliary drainage tubes
consisting of 5-Fr plastic stents (ZEBD-5-4; Cook Medical) ([Video 4 ]).
Fig. 1 Cholangiography showed leakage of contrast media into the abdominal cavity after
the incision into the choledochojejunal anastomosis.
The ulcer-scar-like choledochojejunal anastomosis was found, and a little biliary
flow was detected in the underwater observation.
The choledochojejunal anastomosis was identified using indigo carmine, and an incision
was made with a needle knife.
Incision using the needle knife proceeded toward the light of the SpyGlass
® direct visualization system, which was inserted via the percutaneous transhepatic
cholangiodrainage route as a guide, and the biliary duct was successfully accessed.
The choledochojejunal anastomosis was dilated using a biliary dilator balloon, and
two endoscopic biliary drainage tubes consisting of 5-Fr plastic stents were placed.
A severe stenosis in a choledochojejunal anastomotic site is a significant problem.
DBE-assisted ERCP has already gained acceptance for its less invasive technique and
high-quality performance [2 ]
[3 ], and its applications in rendezvous techniques have been reported [4 ]
[5 ]. Adding to these, the rendezvous technique in combination with SDVS reported here
will expand the possibilities of endoscopic approaches for extremely difficult cases
where DBE-assisted ERCP or PTCD fails to offer patients an alternative that will allow
them to avoid surgery.
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