Endoscopic ultrasound (EUS)-guided antegrade intervention for a hepaticojejunostomy anastomosis obstruction under peroral cholangioscopy via an EUS-guided hepaticogastrostomy route

A 47-year-old man who had undergone subtotal stomach-preserving pancreatoduodenectomy presented with recurrent cholangitis, possibly due to a hepaticojejunostomy anastomosis (HJA) stricture ( Fig. 1 ). Endoscopic retrograde cholangiopancreatography using short-type single-balloon endoscopy was planned. However, as the HJA was completely occluded by a fibrous membrane, we could not insert the cannula into the bile duct. Therefore, we performed endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS).

Fig. 1.

 Computed tomography image showing the dilated intrahepatic bile duct (arrow).

The dilated intrahepatic bile duct (B3) was punctured with a 19-gauge needle (EZ shot 3 plus: Olympus Co., Tokyo, Japan). However, no contrast medium flowed from the dilated bile duct to the jejunum, and a 0.025-inch guidewire could not be inserted across the anastomosis ( Fig. 2 ).

Fig. 2.

 During fluoroscopy, no contrast medium flowed out of the dilated bile duct (arrow).

One month after EUS-HGS, a 7-Fr plastic stent was exchanged for a 6-mm, fully covered, self-expandable metal stent (HANAROSTENT Biliary; M.I. Tech, Gyeonggi-do, Korea) across the EUS-HGS route ( Fig. 3 ). A SpyGlass DS system (Boston Scientific Corp., Marlborough, Massachusetts, USA) was used to perform cholangioscopy to visualize the anastomosis from the inside of the bile duct ( Video 1 ). We found that the duct was completely obstructed at the anastomotic site and covered with a fibrous membrane ( Fig. 4 a ). It was difficult to break through this obstruction even with cholangioscopy guidance. Repeated poking with a stiff edge of a guidewire partially broke the fibrous membrane, and a guidewire could finally be passed thorough the anastomosis; however, a 4-Fr catheter could not be passed through the anastomosis. We dilated the anastomosis stricture by gradually removing the fibrotic tissue using biopsy forceps (SpyBite MAX; Boston Scientific Corp.) under direct cholangioscopic observation ( Fig. 4 b ). After dilation of the anastomosis using a 7-Fr catheter and a 6-mm balloon catheter, antegrade transanastomotic placement of a 7-Fr plastic stent across the EUS-HGS route was performed. No procedure-related adverse events were observed, and cholangitis improved after treatment.

Fig. 3.

 A 6-mm, fully covered, self-expandable metal stent was inserted across the endoscopic ultrasound-guided hepaticogastrostomy route.

Fig. 4.

 Cholangioscopy and fluoroscopy images. a Cholangioscopic image showing the completely obstructed bile duct at the anastomotic site covered with fibrous membrane (arrowheads). b Biopsy forceps were used to remove the fibrotic tissue before dilation of the anastomosis under direct cholangioscopic observation.

Video 1  Endoscopic ultrasound (EUS)-guided antegrade intervention for complete obstruction of a hepaticojejunostomy anastomosis under peroral cholangioscopy via an EUS-guided hepaticogastrostomy route.

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Although EUS-guided drainage for stenosis of the HJA has been reported ¹ , complete obstruction makes it difficult to recanalize the anastomosis using endoscopic procedures. Recently, the usefulness of cholangioscopy through a percutaneous transhepatic or transpapillary route for postoperative biliary strictures or obstructions has been described ^{2 3} . EUS-guided antegrade intervention under cholangioscopy via an EUS-HGS route is an alternative treatment.

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