Unique Approach to Managing Hepatojejunal Anastomotic Stricture in a Patient With a Long Roux-en-Y Limb

Abstract

An anastomotic stricture is a frequent adverse outcome in patients with a Roux-En-Y hepaticojejunostomy. The patient described in this article developed a complicated hepato-jejunal anastomotic stricture with intrahepatic stones that could not be treated with standard balloon enteroscopic interventions due to a very long Roux limb. Thus, a duodenojejunostomy was created to allow access to the stricture and manage the intrahepatic stones. In this case, we convened a multidisciplinary panel of radiologists, surgeons, and interventional endoscopists to consider various therapeutic approaches. The various options were discussed with the patient as part of patient-centered medical decision-making. This patient case highlights the evolving and expanding role of endoscopic ultrasound-directed transenteric interventions for obtaining durable luminal access in patients with altered foregut anatomy, thus providing another avenue for therapeutic interventions which avoid surgery and associated morbidity.

INTRODUCTION

An anastomotic stricture is a known complication of a Roux-en-Y hepaticojejunostomy.¹ Conventionally, such hepatojejunal (HJ) strictures are managed with enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HG).^2,3 We describe a unique approach to managing HJ stricture in a patient with a Roux-en-Y hepaticojejunostomy with a long Roux limb.

CASE REPORT

A 52-year-old woman was referred for the management of intrahepatic stones. Her medical history was notable for a cholecystectomy 28 years ago for cholecystitis which was complicated by an iatrogenic bile duct injury. The bile duct injury eventually necessitated a right hepatectomy and a Roux-en-Y hepaticojejunostomy. Two years ago, she developed abdominal pain and fever and was diagnosed with hepatic abscess along the resection edge, an anastomotic stricture at the hepatojejunostomy, and intrahepatic stones above the stricture. Enteroscope-assisted ERCP was attempted but could not be completed due to a very long roux limb precluding access of the anastomosis. She underwent multiple interventional radiology-guided percutaneous biliary drain placement procedures to resolve symptoms. Eventually, an EUS-guided HG was performed to internalize the drain and allow bile decompression without removal of the biliary stones. She was eventually referred to our center for definitive therapy and clearance of the stones from the bile ducts.

In view of the long roux limb and prior failed enteroscopy-assisted ERCP, creation of an EUS-guided duodenojejunostomy was planned for durable access to the hepaticojejunostomy.

Intervention

To create the duodenojejunostomy, the echoendoscope was positioned in the duodenum and the jejunum identified using EUS. After introducing a 19-gauge fine aspiration needle into the jejunum, contrast was instilled into the jejunal lumen to confirm positioning and identify landmarks (Figure 1). Once confirmed, a lumen apposing metal stent was deployed close to the HJ anastomosis for creation of the duodenojejunostomy (Figure 2).

Figure 1.

Fluoroscopic image depicting contrast in the bowel lumen, confirming creation of the duodenojejunostomy.

Figure 2.

Illustration demonstrating the presence of the hepaticogastrostomy, with the new duodenojejunostomy that created better endoscopic access to the hepatojejunostomy stricture.

After creation of the duodenojejunostomy, a therapeutic gastroscope was used to intubate the jejunum through the duodenojejunostomy and visualize the hepatic limb as well as the hepaticojejunostomy anastomosis stricture. A wire was passed through the HJ as well as the prior HG, and a plastic stent was placed across the HJ while awaiting complete expansion of the lumen apposing metal stent (LAMS) (Figure 3).

Figure 3.

Fluoroscopic image depicting wires in the hepatogastrostomy.

Once the lumen apposing metal stent across the duodenojejunostomy had fully expanded, creation of that duodenojejunostomy allowed for conventional ERCP. The HJ stricture was dilated, the HG metal stent was removed, and a double pigtail stent was placed across the HJ and the HG.

Creation of the duodenojejunostomy allowed for therapeutic upper endoscope access to the HJ, for performance of ERCP to dilate HJ stricture and achieve complete clearance of intrahepatic duct stones. The lumen apposing metal stent creating the duodenojejunostomy was left in place.

During the next procedure 4 weeks later, the intrahepatic stones were easily cleared. All biliary stents were removed at this time, and resolution of HJ stricture was noted with balloon dilations. The lumen-apposing metal stent was left in place to allow for potential future interventions.

Long-term placement of LAMS can be associated with mucosal ulceration from the ends of the stent, migration, occlusion with debris, and increased risk of small intestinal bacterial overgrowth. In a subset of patients, plastic stents can be placed coaxially to maintain patency, especially in patients with infected pancreatic necrosis where there is extensive debris which can clog the LAMS. However, the risk of stent occlusion in our case was relatively lower since the stent lumen was large and exposure to debris minimal. The patient was educated on these risks. She has performed well in the post procedural period as of 1 year after the initial procedure.

DISCUSSION

EUS-guided biliary access is used to facilitate bile drainage in select patients with altered anatomy. In this patient, the HG allowed for bile drainage, but did not resolve underlying stricture and allow for passage of stones. A technique for addressing this had been previously described in the literature but performed in the OR by a general surgeon.³ Other available literature is limited to patients with malignant or benign strictures where the goal was restoring luminal access beyond a mass. Here, we wanted to obtain access for performing a second complicated procedure. This procedure provides an unconventional solution for a unique problem. Multiple other approaches exist for management of complex strictures of the hepaticojejunal anastomosis including double balloon-assisted enteroscopy, percutaneous radiological interventions, and hybrid approaches combining surgical, endoscopic, endosonographic, and radiological techniques. Among these, interventional radiological and enteroscopic approaches have been studied extensively.⁴ While used quite frequently, the data for their use often come from liver transplant recipients and are associated with a relatively high rate of failure.⁵ In a subset of patients, repeat operative interventions may be necessary but remains technically challenging due to its invasive nature, need for meticulous dissection of the adhesions, risk of bleeding and adverse events, and concerns for recurrence of stricture. This unique approach of EUS-guided duodenojejunostomy allowed for long-term access to the HJ, to further manage strictures should they arise. It is also appropriate to mention that creation of a shorter hepaticojejunal limb during the initial surgery is the best option to facilitate subsequent endoscopic biliary interventions.⁶ Available data support short-limb Roux-en-Y hepaticojejunostomy in terms of safety, durability, and ease of biliary access via endoscopic modalities. The approach described in this case may be feasible when first-line and second-line interventions such as interventional radiology (IR)-guided and balloon enteroscopy-guided interventions have been tried and the patient needs durable access for multiple interventions over time.

DISCLOSURES

Author contributions: N. Puri performed all of the procedures described in the manuscript and reviewed the case report. P. Smith wrote the case report. N. Puri is the article guarantor.

Financial disclosure: This study was not supported by any sponsor or funder. The authors have no conflicts of interest to declare.

Previous presentation: Previously presented at ACG annual meeting in Philadelphia, PA, October 25–29, 2024.

Informed consent was obtained for this case report.

ABBREVIATIONS:

ERCP

endoscopic retrograde cholangiopancreatography

EUS

endoscopic ultrasound

HG

hepaticogastrostomy

HJ

hepatojejunostomy/hepatojejunal

IR

interventional radiology

LAMS

lumen-apposing metal stent

OR

operating room