Biliary drainage in patients with altered anatomy usually requires either percutaneous
biliary drainage or endoscopic retrograde cholangiopancreatography (ERCP) performed
with enteroscopy, so called e-enteroscopy [1]. In a meta-analysis, e-enteroscopy was successful in 70 % of cases, with a mean
procedure duration of > 80 minutes [2]. Endoscopic ultrasound (EUS)-guided antegrade drainage using a previous EUS-guided
hepaticogastrostomy is the most commonly performed EUS procedure in altered anatomy,
with technical and clinical success rates ranging from 85 % to 91.9 % [3]
[4]. In cases of bariatric gastric bypass, EUS-directed transgastric ERCP is a technique
used to access the excluded stomach after Roux-en-Y- bariatric bypass through gastrogastrostomy
with the duodenoscope [1].
A 73-year-old woman was referred with jaundice. She had undergone Whipple surgery
for a tumor in the pancreatic head seven years ago. Pathological analysis showed a
5-cm pancreatic neuroendocrine tumor, WHO grade 2, pT3N0M0, Ki-67 6 %. During follow-up,
liver metastasis occurred with jaundice and pruritus. Magnetic resonance imaging at
the last investigation showed invasion of the hilum of the liver with dilatation of
biliary ducts in the right lobe and complete atrophy of the left lobe.
Management with EUS-guided hepaticogastrostomy was not possible and e-enterosocopy
failed. To avoid percutaneous biliary drainage, we decided to access the afferent
limb of the surgical hepaticojejunostomy by performing EUS-guided gastrojejunostomy
([Fig. 1], [Fig. 2] and [Fig. 3]), then accessing the choledochojejunal surgical anastomosis (EUS-GJ) ([Fig. 4]). Under EUS guidance, an EUS-guided gastrojejunal anastomosis was performed through
the antrum wall with direct approach ([Video 1]). The postoperative course was uneventful.
Fig. 1 Endoscopic ultrasound puncture of the afferent limb through the gastric wall.
Fig. 2 X-ray view of the release of the distal flange.
Fig. 3 Endoscopic view of the release of the proximal flange.
Fig. 4 Cholangiography with the axial scope.
Video 1 Endoscopic ultrasound-guided gastrojejunostomy with the afferent limb, followed by
endoscopic retrograde cholangiopancreatography through the gastrojejunostomy.
Three weeks later, an ERCP was performed through the EUS-GJ with a colonoscope easily
reaching the choledochojejunal anastomosis ([Fig. 4]). Biliary drainage was performed by inserting two plastic stents. The postoperative
course was uneventful, with complete resolution of the jaundice.
Endoscopy_UCTN_Code_TTT_1AR_2AK
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
