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Stenosis of Hepaticojejunal Anastomosis with Intrahepatic Lithiasis: Treatment with Single-Balloon Enteroscopy-Assisted ERCP

Authors:
Jaime Pereira Rodrigues at Centro Hospitalar de Vila Nova de Gaia/Espinho
Jaime Pereira Rodrigues
Rolando Pinho at Centro Hospitalar de Vila Nova de Gaia/Espinho
Rolando Pinho
Luisa Proença at Centro Hospitalar de Vila Nova de Gaia/Espinho
Luisa Proença
Joana Silva at Universidade Católica Portuguesa
Joana Silva
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Endoscopic Snapshot
GE Port J Gastroenterol
DOI: 10.1159/000484251
Stenosis of Hepaticojejunal Anastomosis
with Intrahepatic Lithiasis: Treatment with
Single-Balloon Enteroscopy-Assisted ERCP
JaimeP.Rodrigues RolandoPinho LuísaProença JoanaSilva AnaPonte
MafaldaSousa JoãoCarlosSilva JoãoCarvalho
Gastroenterology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia , Portugal
kyo, Japan) with a transparent cap attached at its tip. After
identification of the Roux-en-Y anastomosis, the afferent
limb was intubated, followed by progression to the he-
paticojejunal anastomosis. A severe stricture of the anas-
tomosis was identified ( Fig. 1 ). A 0.035-inch guidewire
(METII-35-600E, Tracer Metro
® Direct TM Wire Guide,
Cook
® , Bloomington, IN, USA) was passed through the
stricture followed by a sphincterotome (CCPT-25ME,
Classic Cotton
® CannulaTome ® , Cook ® ). Upon contrast
injection, dilation of the intrahepatic ducts was evident.
Dilation with a 6- to 8-mm through-the-scope balloon
(34106PRO, Endo-Flex
® , Düsseldorf, Germany) was
then performed ( Fig.2 , 3 ) with immediate spontaneous
drainage of multiple small calculi. The intrahepatic bile
ducts were explored with a balloon catheter, but no more
calculi were identified. The patient was discharged on the
second day after the procedure and did not present addi-
tional episodes of acute cholangitis after a 6-month fol-
low-up.
ERCP is an essential therapeutic technique for a wide
range of pancreatobiliary conditions and presents a 90–
95% success rate in patients with native gastric and pan-
creaticoduodenal anatomy [1] . In Roux-en-Y surgical
reconstruction (hepaticojejunostomy and choledocho-
jejunostomy, gastric bypass surgery, or post-Whipple
surgery), ERCP is often unsuccessful because of the in-
Keywords
ERCP · Enteroscopy · Stricture · Dilation
Estenose de Anastomose Hepatico-Jejunal com
Litíase Intra-Hepática: Tratamento por CPRE
Assistida por Enteroscópio de Mono-Balão
Palavras Chave
CPRE · Enteroscopia · Estenose · Dilatação
A 53-year-old male patient with a history of Roux-en-
Y hepaticojejunostomy due to an iatrogenic lesion of the
biliary tract during cholecystectomy in 2013 presented
with recurrent episodes of acute cholangitis. Magnetic
resonance cholangiopancreatography showed dilation of
the intrahepatic biliary ducts associated with intrahepatic
lithiasis. Due to a high index of suspicion of hepaticojeju-
nal anastomosis stenosis not evident in the magnetic res-
onance cholangiopancreatography, the patient was re-
ferred to our department for enteroscopy-assisted endo-
scopic retrograde cholangiopancreatography (ERCP).
The procedure was performed with a single-balloon en-
teroscope (SIF-Q180, Olympus Medical Systems
® , To-
Received: April 27, 2017
Accepted after revision: August 9, 2017
Published online: November 16, 2017
Dr. Jaime P. Rodrigues
Gastroenterology Department, Centro Hospitalar Vila Nova de Gaia/Espinho
Rua Conceição Fernandes
PT–4434-502 Vila Nova de Gaia (Portugal)
E-Mail jaimepereirarodrigues @ gmail.com
© 2017 Sociedade Portuguesa de Gastrenterologia
Published by S. Karger AG, Basel
www.karger.com/pjg is article is licensed under the Creative Commons Attribution-
NonCommercial-NoDerivatives 4.0 International License (CC BY-
NC-ND) (http://www.karger.com/Services/OpenAccessLicense).
Usage and distribution for commercial purposes as well as any dis-
tribution of modi ed material requires written permission.
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Rodrigues/Pinho/Proença/Silva/Ponte/
Sousa/CarlosSilva/Carvalho
GE Port J Gastroenterol
DOI: 10.1159/000484251
2
ability to reach the anastomosis [1] . Double-balloon en-
teroscopy was initially introduced as a useful procedure
to access surgically excluded intestinal segments [2] . Pos-
teriorly, single-balloon enteroscope, an alternative meth-
od for small-bowel evaluation, proved to be safe and use-
ful for engaging in biliary endotherapy [1, 3, 4] . However,
the technique presents several limitations, namely the
frontal view of the enteroscope (as opposed to the lateral
view of conventional duodenoscopes), the smaller caliber
channel, and the longer channel length [5] . Moreover,
available standard ERCP accessories cannot be used with
the enteroscope [5] . These limitations turn the procedure
challenging and more demanding than standard ERCP.
The use of a cap attached to the distal tip of the entero-
scope can improve the endoscopic position and add sta-
bility for biliary cannulation. In consequence, and in con-
trast to patients with native anatomy, in patients with he-
paticojejunal anastomosis the cannulation success rate is
approximately 70% [1] .
This case illustrates the gradual improvement of en-
doscopic biliary interventions in patients with surgically
altered anatomy. With the development of device-assist-
ed ERCP, access to the pancreatic and biliary duct sys-
tems in patients with surgically altered anatomies is now
possible, although technically challenging and time con-
suming.
Disclosure Statement
The authors do not have any interest which might be inter-
preted as influential in this report. This report did not receive any
support from corporations, industrial or private.
Fig. 1. Endoscopic view of the hepaticojejunal anastomotic stric-
ture (short arrow) in a 53-year-old male with a history of Roux-en-
Y hepaticojejunostomy performed after iatrogenic bile duct injury
during cholecystectomy.
Fig. 2. Endoscopic view of the dilation procedure with a 6- to
8-mm through-the-scope balloon (34106PRO, Endo-Flex
® , Düs-
seldorf, Germany).
Fig. 3. Endoscopic image showing the anastomosis after dilation.
The guidewire can be seen positioned inside the intrahepatic bili-
ary ducts.
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Stenosis of Hepaticojejunal Anastomosis
with Intrahepatic Lithiasis
GE Port J Gastroenterol
DOI: 10.1159/000484251
3
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3 Pinto-Pais T, Pinho R, Proença L, et al: Iatro-
genic biliary injury in a patient with Roux-en-
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Biliary self-expandable metallic stent using single balloon enteroscopy assisted ERCP - Overcoming limitations of current accessories
Article
Full-text available
  • Oct 2013
  • REV ESP ENFERM DIG
Device assisted enteroscopy (DAE) techniques have been recently developed for the diagnosis and treatment of small bowel diseases. These techniques can also be used to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomies. The main difficulties with DAE-ERCP are related to type of surgery, to the different dimensions and lack of frontal view of the enteroscope and to the resulting limitations with the use of standard accessories, resulting in the need of dedicated accessory devices. Although most ERCP techniques have been successfully performed with DAE-ERCP, biliary self-expandable metallic stents (SEMS) have not yet been used, as dedicated biliary SEMS for the enteroscope are lacking. The authors present a case report showing a new method to place standard biliary trough-the-scope SEMS with DAE-ERCP, using a different technique of stent deployment.
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Double-balloon enteroscopy for choledochojejunal anastomotic stenosis after hepato-biliary-pancreatic operation
Article
  • Jul 2014
  • DIGEST ENDOSC
Background There have been few reports on the success rate of balloon dilation and stent deployment using DBE-ERCP (endoscopic retrograde cholangiopancreatography by double-balloon enteroscopy) or on the follow-up period after stent removal in patients with a reconstructed digestive tract and stenosis of choledochojejunal anastomosis. This study was designed to evaluate the usefulness of DBE-ERCP in patients with a reconstructed digestive tract and stenosis of choledochojejunal anastomosis.Methods Forty-four patients with stenosis of choledochojejunal anastomosis underwent DBE-ERCP at our hospital between April 2008 and January 2012 (107 procedures). The rates of reaching of choledochojejunal anastomosis, stent deployment, and restenosis after stent removal were retrospectively evaluated.ResultsThe insertion of DBE into choledochojejunal anastomotic site succeeded in 38 of 44 patients (86.4%), and anastomotic dilation and stent deployment succeeded in 36 of 44 patients (81.8%). In 32 of 44 patients (72.7%), their anastomotic stenoses were improved, and they achieved stent removal. After stent removal, restenosis of choledochojejunal anastomosis was detected in 7 of 32 patients; however, the resolution of restenosis achieved in all 7 of those patients.Conclusion Dilation of choledochojejunal anastomosis combined with stent deployment using DBE-ERCP seems to be a viable first-line treatment for patients with stenosis of choledochojejunal anastomosis.
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Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy
Article
  • Aug 2010
  • ENDOSCOPY
Endoscopic retrograde cholangiopancreatography (ERCP) is challenging to perform in patients with postsurgical gastrointestinal anatomy. We assessed the diagnostic and therapeutic success rates using single-balloon enteroscopy in patients with Roux-en-Y anastomosis. Patients who underwent single-balloon ERCP between April 2008 and February 2010 were retrospectively identified using a computerized endoscopy database. Diagnostic success was defined as successful duct cannulation or securing the diagnosis, and therapeutic success was defined as the ability to successfully carry out endoscopic therapy. Complications of ERCP were defined according to standard criteria. A total of 50 patients (34-male, mean age 57 years, range 19 - 85 years) with Roux-en-Y anastomosis underwent ERCP using a single-balloon enteroscope on 56 occasions. Indications for ERCP were cholestasis, acute cholangitis, recurrent primary sclerosing cholangitis with strictures, and choledocholithiasis. Overall diagnostic success was achieved in 39 / 56 cases (70 %). Therapeutic success was achieved in 21/23 cases (91 %). In 16 cases therapeutic intervention was not required. Therapeutic interventions included balloon dilation of strictures (n = 14), retrieval of retained biliopancreatic stents (n = 5), biliary stone extraction (n = 2), insertion of biliopancreatic stents (n = 4), and biliary and pancreatic sphincterotomy (n = 5). No major complications occurred. Importantly, in 22 / 56 procedures (39 %) a prior attempt at ERCP failed using conventional colonoscopes; single-balloon ERCP was successful in 15 / 22 (68 %) of these cases. Single-balloon ERCP is feasible in patients with complex postsurgical Roux-en-Y anastomosis, allows diagnostic evaluation and therapeutic intervention in patients with pancreaticobiliary disease, and is a useful salvage technique in the majority of patients in whom ERCP using colonoscopies has failed.
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Single-Balloon Enteroscopy Effectively Enables Diagnostic and Therapeutic Retrograde Cholangiography in Patients with Surgically Altered Anatomy
Article
  • Mar 2010
In patients with surgically altered anatomy, ERCP is often unsuccessful. Single-balloon enteroscopy (SBE) enables deep intubation of the small bowel, permitting diagnostic and therapeutic ERCP in this subset of patients. To determine the effectiveness of SBE in performing endoscopic retrograde cholangiography (ERC) in patients with surgically altered anatomy. Case series. Large quaternary-care center. Thirteen patients (11 women) underwent 16 SBE procedures with ERCP. Patient anatomy consisted of Whipple (n = 3), hepaticojejunostomy (n = 3), Billroth II (n = 1), and Roux-en-Y (n = 9). Patients with surgically altered anatomy in whom standard ERCP techniques had failed or were not possible underwent ERC by using SBE with initial therapeutic intent. Success rates of diagnostic ERC and therapeutic ERC in those patients who required biliary intervention. Procedure-related complications were also assessed. Diagnostic ERC was successful 12 (92.3%) of 13 patients and in 13 (81.3%) of 16 cases. Therapeutic ERC was required in 10 patients in whom diagnostic ERC was first accomplished, and therapeutic ERC was successful in 9 (90%) of 10 patients. Biliary interventions included balloon dilation (n = 4), stone extraction (n = 2), sphincterotomy (n = 4), removal of a surgically placed stent (n = 3), and stenting (n = 2). Two patients developed pancreatitis after therapeutic ERC. Median follow-up was 53 days (range 22-522 days). Overall procedural success in an intent-to-treat analysis by case was 75%. Single-center experience. SBE enables diagnostic and therapeutic ERC in most patients with altered anatomy. SBE-assisted therapeutic ERC may be associated with an increased risk of pancreatitis. Improvement of the available equipment is necessary to perform more efficient and effective biliary interventions.
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