A 27-year-old man with unresectable periampullary neoplasm underwent a Roux-en-Y hepaticojejunostomy
with gastrojejunostomy 1 year previously. He presented with a 1-month history of progressive
yellowish discoloration of his eyes, abdominal pain and distension, and intermittent
high fever with chills and rigors. On admission his results showed a bilirubin of
9 mg/dL, alkaline phosphatase of 1467 IU/mL, and total white blood cell (WBC) count
of 28 700/mm3. A blood culture grew Escherichia coli. A contrast-enhanced computed tomography (CT) scan of the abdomen showed a grossly
dilated loop of jejunum with distal obstruction, in communication with a patent hepaticojejunostomy
anastomosis ([Fig. 1]).
Fig. 1 Contrast-enhanced computed tomography (CT) scan of the abdomen showing a dilated
loop of jejunum with an intact hepaticojejunostomy anastomosis.
We planned to decompress the jejunal loop to relieve the cholangitis; however, the
presence of a distal obstruction precluded enteroscope-assisted drainage. The distended
jejunal loop was punctured with a 10-Fr cystotome (Cook Medical, Winston-Salem, North
Carolina, USA) using endoscopic ultrasound (EUS) guidance ([Fig. 2 a]). The needle was removed and a 0.035-inch guidewire was placed through the inner
catheter into the jejunal loop. The over-the-wire 10-Fr outer catheter of the cystotome
with a diathermic ring was advanced into the jejunal loop using pure cut ([Video 1]). The cystotome was then removed. A 30-mm Niti-S Nagi stent (Taewoong Medical, Seoul,
South Korea) was placed across the tract between the stomach and jejunal limb ([Fig. 2 b]), and bile was seen to drain through the gastrojejunal anastomosis ([Fig. 3 a]). To prevent migration of the stent, a 7-Fr double-pigtail plastic stent (7 cm in
length) was placed across the Nagi stent ([Fig. 3 b]).
Fig. 2 Endoscopic ultrasound (EUS) images showing: a the puncture of the dilated jejunal loop with a 10-Fr cystotome; b the Niti-S Nagi stent being deployed over the wire.
Radiographic and endoscopic views of the dilated jejunal loop being punctured, a
Nagi stent being positioned across the gastrojejunostomy, with a double-pigtail stent
positioned through it to prevent migration.
Fig. 3 Endoscopic views showing: a the Niti-S Nagi stent in position allowing free flow of bile across the gastrojejunostomy;
b a 7-Fr double-pigtail plastic stent (7 cm in length) that has been inserted through
the stent to prevent migration.
After the procedure the patient’s fever subsided, his bilirubin decreased to 3.1 mg/dL,
his total WBC count decreased to 15 200/mm3 and he was moved from the intensive care unit. He was discharged from hospital after
15 days.
Obstruction of the jejunal loop can occur as a late complication of hepaticojejunostomy
due to either adhesions or tumor recurrence. EUS-guided gastrojejunostomy for afferent-loop
syndrome using a Hot Axios stent was first described by Ikeuchi et al. in 2015 [1]. Mutignani et al. recently used the Nagi stent to gain access to the jejunal loop
in a patient with an hepaticojejunostomy [2]. In our patient, we used the Nagi stent to decompress the obstructed jejunal loop. The
procedure appears to be a safe alternative for the management of patients with hepaticojejunostomy
presenting with cholangitis secondary to jejunal loop obstruction.
Endoscopy_UCTN_Code_TTT_1AS_2AD
