Endoscopic ultrasound-guided choledochojejunostomy using a forward-viewing echoendoscopic saddle-cross technique

We reported good results for endoscopic treatment of benign hepaticojejunostomy anastomotic stricture (HJAS) using two fully covered self-expandable metallic stents (FCSEMSs) with the saddle-cross technique [1]. A completely occluded HJAS requires drainage by percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) [2]; PTBD and EUS-HGS cannot be stent-free, which may decrease patients’ activities of daily living. We present a modified saddle-cross technique for a completely occluded HJAS using a forward-viewing echoendoscope and two FCSEMSs.

A 30-year-old man underwent duodenal gastrointestinal stromal tumor surgery. Liver dysfunction occurred 1 year postoperatively; computed tomography showed bile duct dilatation ([Fig. 1]). The transgastrointestinal approach and breakthrough in anastomosis under PTBD failed. The patient was referred to our hospital for internal fistulization ([Fig. 2]).

Fig. 1 Computed tomography scan showing dilation of the right and left bile ducts from the beginning of the hepaticojejunostomy anastomosis (arrow). a Axial image. b Coronal image.

Fig. 2 Hepaticojejunostomy anastomotic stenosis approach from percutaneous transhepatic biliary drainage (PTBD). a Contrast from the PTBD shows complete occlusion of the hepaticojejunostomy anastomosis. b The guidewire could not pass through the hepaticojejunostomy anastomosis. c Contrast did not flow when the catheter was pressed against the hepaticojejunostomy anastomosis.

Endoscopic ultrasound (EUS)-guided choledochojejunostomy using a forward-viewing endoscope (TGF-UC260J; Olympus Medical Systems, Tokyo, Japan) with the saddle-cross technique was performed for internal fistulization ([Video 1]). A forward-viewing endoscope was inserted up to the HJAS; anastomosis was confirmed using endoscopy and ultrasound ([Fig. 3]). The bile duct was punctured through the anastomosis using a 19-gauge needle (EZ shot 3 plus; Olympus Medical Systems), and a 0.025-inch guidewire (M-through; Medicoʼs Hirata, Osaka, Japan) was advanced into the bile duct. The fistula was dilated using an electrocautery dilator (Fine025; Medicoʼs Hirata) and an 8-mm dilation balloon (REN; Kaneka, Tokyo, Japan). Two guidewires were placed in the right and left bile ducts and two FCSEMSs (BONASTENT M-Intraductal, 8 mm, 3 cm; Medico's Hirata) were placed ([Fig. 4]). After PTBD removal, the two FCSEMSs were endoscopically removed 2 months postoperatively. Sufficient dilation of the fistula was observed ([Fig. 5]). The patient experienced no restenosis 6 months postoperatively.

Video 1 Internal fistulization of completely occluded hepaticojejunostomy anastomotic stricture is difficult. We performed endoscopic ultrasound-guided choledochojejunostomy using a forward-viewing echoendoscope and two metallic stents with a modified saddle-cross technique.

Fig. 3 Trans-gastrointestinal endoscopic approach for hepaticojejunostomy anastomotic stenosis using a forward-viewing echoendoscope. a Endoscopic image of hepaticojejunostomy anastomotic stenosis. b Endoscopic ultrasound image of hepaticojejunostomy anastomotic stenosis (yellow arrow). c Radiograph of hepaticojejunostomy anastomotic stenosis.

Fig. 4 Endoscopic ultrasound (EUS)-guided choledochojejunostomy. a Puncture of the bile duct under EUS guidance using a 19-gauge needle. b Contrast enhancement confirms the bile duct. c Fistula dilation with an energized dilator. d Fistula dilation with a balloon dilator. e Endoscopic image of the fistula after dilation. f Two guidewires are placed in the right and left bile ducts. g Two fully covered self-expanding metal stents (FCSEMSs) are placed. h Endoscopic image after placement of the FCSEMSs.

Fig. 5 Endoscopic removal of two FC-SEMSs 2 months after the procedure. a Radiograph of the two FCSEMSs. b Endoscopic image of the two FCSEMSs. c Endoscopic image after FCSEMS removal. d Radiograph shows good contrast spillage.

Although there are reports on EUS-guided choledochojejunostomy [3] [4], this is the first on treatment using a modified saddle-cross technique, which may be an option for primary endoscopic treatment of a completely occluded HJAS.

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• References

• 1 Kawasaki Y, Hijioka S, Nagashio Y. et al. A novel endoscopic technique using fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy: The saddle-cross technique (with video). Surg Endosc 2022;
• 2 Tanisaka Y, Ryozawa S, Mizuide M. et al. Analysis of the factors involved in procedural failure: Endoscopic retrograde cholangiopancreatography using a short-type singe-balloon enteroscope for patients with surgically altered gastrointestinal anatomy. Dig Endosc 2019; 31: 682-689
• 3 Itoi T, Ikeuchi N, Tonozuka R. et al. EUS-guided choledochojejunostomy with a lumen-apposing metal stent in a post-Whipple patient. Gastrointest Endosc 2015; 81: 1259-1260
• 4 Kikuyama M, Aoyama H, Kyoden Y. Endoscopic ultrasonography-guided choledochojejunostomy: Novel method to treat a severely stenotic choledochojejunal anastomosis. Dig Endosc 2016; 28: 221