Endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy is a challenging procedure [1]. Transjejunal ERCP through endoscopic ultrasound (EUS)-guided enteroanastomosis appears to be a safe and effective technique [2]. We report a 65-year-old woman with a previous Roux-en-Y hepaticojejunal anastomosis presenting with acute bacterial cholangitis complicated by septic shock. She underwent unsuccessful enteroscopy-assisted ERCP. Given her altered anatomy, an EUS-guided approach was offered ([Video 1]).
Endoscopic ultrasound-guided hepaticojejunostomy through an endoscopic ultrasound-guided enteroanastomosis.Video 1
A forward-viewing scope was advanced to the afferent limb, and a nasobiliary drainage (G21583; Cook Medical, Bloomington, Indiana, USA) was placed with connection to a water pump. A linear echoendoscope (GF-UCT 180; Olympus, Tokyo, Japan) connected to an ultrasound processor (Arietta 850; Fujifilm, Tokyo, Japan) was used, and by pumping water into the afferent limb this provided a clear view for creating a duodenojejunostomy with a 15-mm lumen-apposing metal stent (LAMS) (Axios; Boston Scientific, Marlborough, Massachusetts, USA) to access the biliary tree ([Fig. 1]). After allowing time for tract maturation, the duodenojejunostomy was accessed with a duodenoscope, but cannulation was not possible due to a very tight angulated stricture. A decision was made to access the LAMS with a forward-viewing echoendoscope (TGF-UC180J; Olympus) to create a new biliary anastomosis. The common hepatic duct was identified and punctured with a 19G needle ([Fig. 2]) (EZ Shot 3 Plus; Olympus). Confirming adequate location with a cholangiogram ([Fig. 3]), a 0.025-inch guidewire (VisiGlide; Olympus) was advanced. A cystotome (G30550; Cook Medical) was fed in, and a new hepaticojejunostomy was created and dilated up to 12 mm with a pneumatic balloon ([Fig. 4]) (CRE Rx; Boston Scientific). To finalize, 3 biodegradable 10 Fr stents (Archimedes; Q3 Medical Group, Dublin, Ireland) were placed. After successful drainage the patient improved, and no complications related to the procedure were documented.
Fig. 1 Ultrasound image showing placement of lumen-apposing stent to access the biliary tree in a 65-year-old woman with acute bacterial cholangitis and altered anatomy after previous Roux-en-Y hepaticojejunal anastomosis.
Fig. 2 Ultrasound image showing common hepatic duct punctured by a 19G fine-needle aspiration needle.
Fig. 3 Endoscopic ultrasound (EUS)-guided cholangiogram showing successful puncture of the common hepatic duct.
Fig. 4 Cholangiogram showing balloon dilation of the newly created EUS-guided hepaticojejunostomy.
EUS-guided enterostomy with hepaticojejunostomy drainage offers a novel alternative for bile duct access in patients with altered anatomy.
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E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).
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