Roux-en-Y biliodigestive reconstruction excludes the biliary tract from conventional
endoscopic retrograde cholangiopancreatography (ERCP) [1 2 3 4 5
We report two DBE interventions in one patient who had developed a hepaticojejunostomy
stricture after resection of the right lobe of the liver. This 72-year-old man with
a Klatskin IIIa tumor underwent curative right hepatectomy and Roux-en-Y hepaticojejunostomy
in 2004. Two years later, he presented with cholangitis and dilatation of the intrahepatic
biliary tree in the remaining left liver without any evidence of tumor recurrence
on magnetic resonance imaging. With the patient under general anesthesia, we reached
the hepaticojejunostomy using the Fujinon EN-450T5 therapeutic DBE (Fujinon Corporation,
Saitama-Shi, Saitama, Japan). The anastomosis was impacted with sludge entrapped in
remaining sutures ([Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 6
Figure 1 Endoscopic view of the hepaticojejunostomy during the first procedure showing sludge
impacted in the remaining sutures.
Figure 2 Radiologic view of balloon dilation of the hepaticojejunostomy up to 6 mm using a
conventional esophageal dilation balloon. The balloon is filled with diluted iodinated
contrast material (procedure 1).
Figure 3 Endoscopic view of the dilated hepaticojejunostomy at the end of the first procedure.
Note the remaining surgical sutures.
Figure 4 Radiologic view of the cholangiography after a new access to the dilated left hepatic
branch had been created using a sclerosing needle. The cholangiography was performed
with a dilation balloon in place (procedure 2).
Figure 5 Endoscopic view of biliary stent (7 Fr) placement over a guide wire, using a nasobiliary
catheter as a pushing device. The first biliary stent is already in position (procedure
2).
Figure 6 Radiologic view of the two biliary stents located in the hepaticojejunostomy. Note
the air cholangiography at the end of procedure 2.
Evidence is emerging that DBE allows ERCP interventions after Roux-en-Y surgery. Although
it remains an elaborate procedure, it might prevent the need for redo surgery. Accessories
adapted to the therapeutic DBE should be made available to enable further developments
for this new indication.
Endoscopy_UCTN_Code_TTT_1AP_2AD
Endoscopy_UCTN_Code_TTT_1AR_2AG
Endoscopy_UCTN_Code_TTT_1AR_2AK
