Indeterminate biliary stricture treated by antegrade cholangioscopy through an endoscopic ultrasound-guided hepaticojejunostomy

Indeterminate biliary strictures represent a clinical challenge [1] [2]. Endoscopic retrograde cholangiopancreatography (ERCP) with brushings and transpapillary biopsies have limitations in terms of their sensitivity and specificity [3] [4]. Cholangioscopy plays a relevant role in this field with a high sensitivity for the macroscopic appearance [5].

A 60-year-old woman, who had undergone total gastrectomy with Roux-en-Y reconstruction for gastric adenocarcinoma (pT2 N0 M0) 4 years previously, presented to our ambulatory unit with upper abdominal pain and alteration of liver function tests. An abdominal computed tomography scan ([Fig. 1]) and magnetic resonance cholangiopancreatography (MRCP) ([Fig. 2]) showed bile duct dilatation and a distal stricture of the common bile duct. However, an endoscopic ultrasound (EUS) approach was not feasible or effective because of her altered anatomy.

Fig. 1 Abdominal computed tomography scan showing bile duct dilatation.

Fig. 2 Magnetic resonance cholangiopancreatography showing bile duct dilatation and a filling defect in the papillary area.

A first attempt to reach the papillary area and perform a subsequent ERCP using a pediatric colonoscope was unsuccessful owing to the length and angulations of the jejunal loop. Therefore, a hepaticojejunostomy was performed endoscopically ([Fig. 3 a]). First, a transjejunal hepatic EUS-guided puncture was done using a 19 G needle. A guidewire was pushed through the transjejunal access through the papillary area retrogradely and was recovered through the pediatric colonoscope ([Fig. 3 b]). The papilla was cannulated from distance under fluoroscopic guidance (because of a tight angulation at Treitz’s ligament) using a 12-mm Fogarty balloon. Cholangiography confirmed homogeneous dilatation of the bile ducts with a distal stricture. The stricture was dilated using a 10-mm pneumatic balloon; brushings and transpapillary biopsies were then performed. A 10-Fr 12-cm biliary plastic stent was left in place to maintain patency of the endoscopic hepaticojejunostomy.

Fig. 3 Fluoroscopic images showing: a an endoscopic ultrasound-guided hepaticojejunostomy being created; b the guidewire that had been passed through the transjejunal access and through the papillary area retrogradely being recovered with the pediatric colonoscope.

Because the cytology was non-diagnostic, antegrade cholangioscopy using the SpyGlassDS system (Boston Scientific Co.) was successfully performed through the endoscopic hepaticojejunostomy 2 weeks later ([Video 1]). The appearance of the stricture was non-malignant; several cholangioscopic biopsies were taken using a SpyBite (Boston Scientific Co.), which later confirmed there was no cellular atypia on histopathology. Finally, a 10-Fr 12-cm biliary plastic stent was positioned through the hepaticojejunostomy.

Video 1 Antegrade cholangioscopy through an endoscopic ultrasound-guided hepaticojejunostomy to treat a biliary indeterminate stricture in a patient with Roux-en-Y reconstruction.

No early adverse events occurred and the patient was discharged the day after the procedure. At her 1-month follow-up visit, the patient had developed two liver abscesses (S4 – S8), which were probably related to bile duct contamination during the cholangioscopy. Percutaneous drainage of the abscesses was performed, and the patient was found to be doing well at her 3-month follow-up visit.

Endoscopy_UCTN_Code_TTT_1AS_2AD

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Singh A, Gelrud A, Agarwal B. Biliary strictures: Diagnostic considerations and approach. Gastroenterol Rep (Oxf) 2015; 3: 22-31
• 2 Kato M, Onoyama T, Takeda Y. et al. Peroral cholangioscopy-guided forceps biopsy and endoscopic scraper for the diagnosis of indeterminate extrahepatic biliary stricture. J Clin Med 2019; 8: 1-11
• 3 Ponchon T, Gagnon P, Berger F. et al. Value of endobiliary brush cytology and biopsies for the diagnosis of malignant bile duct stenosis: results of a prospective study. Gastrointest Endosc 1995; 42: 565-572
• 4 Burnett AS, Calvert TJ, Chokshi RJ. Sensitivity of endoscopic retrograde cholangiopancreatography standard cytology: 10-y review of the literature. J Surg Res 2013; 184: 304-311
• 5 Navaneethan U, Njei B, Lourdusamy V. et al. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: A systematic review and meta-analysis. Gastrointest Endosc 2015; 81: 168-176

Publication History

Article published online:
24 April 2020