DOUBLE BALLOON ENTEROSCOPY ERCP RENDEZVOUS TECHNIQUE

Balloon-assisted enteroscopy ERCP is now an accepted procedure to perform interventions in patients with complex post-surgical anatomy. However, passage of dilating balloons, larger diameter plastic and metal stents is limited by the size of the working channel of the enteroscope. In addition, when the scope is torqued and looped, even the passage of smaller caliber accessories may be impossible. If the patient has a percutaneous stent, then the DBE-ERCP rendezvous technique presented herein can be attempted, resulting in successful placement of larger diameter plastic and self-expanding metal stents.

A 30 year-old woman with autoimmune hepatitis who had undergone liver transplantation with Roux-en-Y hepaticojejunostomy (HJ) presented with bile duct strictures. A percutaneous transhepatic drain (PTCD) had been placed to relieve the bile duct stricture but she had ongoing abdominal pain at the site of the PTCD. Thus, she was referred to us for double balloon enteroscopy (DBE) assisted ERCP to attempt internalization of the biliary drainage. The DBE was advanced to the afferent limb where two PTC stents were seen exiting the HJ (Figure 1). Cholangiogram showed the PTCD lying across the stenoses (Figure 2). Due to massive looping of the endoscope it was impossible to advance any stents through the scope. Thus, it was decided to first dilate the HJ and then place the endoscopic stent form outside, i.e. through-the-skin. A Metro wire was advanced percutaneosuly into the jejunum across the HJ. The external/internal PTCD was then removed. The balloon dilator was advanced from outside and dilation was performed both under direct endoscopic and fluoroscopic visualization. Then two 10 Fr 7 cm long plastic stents was inserted over-the wire. The patient had an uneventful recovery and no more pain at the ex-PTCD site. The stents were removed three months later after complete resolution of the stenosis of the hepaticojejunostomy.