Successful endoscopic dilation of severe bilioenteric strictures with a wire-guided diathermic dilator and short-type single-balloon enteroscope

Recently, balloon enteroscopy has made possible the use of endoscopic approaches to the surgically reconstructed intestine [1] [2] [3] [4], so that hepaticojejunostomy strictures can be treated endoscopically. We describe the successful endoscopic dilation of a severe hepaticojejunostomy stricture with a wire-guided diathermic dilator (6-Fr, 180-cm Cysto-Gastro-Set; Endo-flex, Voerde, Germany) ([Fig. 1]).

Fig. 1 A 6-Fr wire-guided diathermic dilator (Cysto-Gastro-Set), with a working length of 180 cm and a maximum diameter of 2.0 mm, can be used to dilate severe hepaticojejunostomy strictures.

A 66-year-old woman underwent pylorus-preserving pancreaticoduodenectomy for cancer of the pancreatic head. Cholangitis due to bilioenteric stricture developed at the third month after surgery. A short-type, single-balloon enteroscope (SIF-Y0004V01; Olympus Medical Systems, Tokyo, Japan) was used to perform balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography (ERCP). A 0.025-inch guidewire could pass through the stricture, but an ERCP imaging catheter with a tapered tip, 1.8 to 2.3 mm in diameter (MTW Endoskopie, Wesel, Germany), and a 6-Fr Soehendra Biliary Dilation Catheter (Cook Medical, Winston-Salem, North Carolina, USA) could not.

A guidewire was placed in a hepatic duct, and the anastomotic stricture was electrically dilated with a 6-Fr Cysto-Gastro-Set. After the dilation procedure, an imaging catheter could be passed through the stricture. The anastomosis was dilated with a 6.8-Fr Quantum TTC Biliary Balloon Dilator 6 mm in diameter (QBD-6X3; Cook Medical), after which the cholangitis decreased ([Video 1]). There were no adverse events. The stricture was classified as a type A1 stricture according to the classification of Mönkemüller & Jovanovic [4].

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Endoscopic dilation of a severe bilioenteric stricture with a wire-guided diathermic dilator.

In patients who undergo balloon enteroscope-assisted ERCP for hepaticojejunostomy strictures, a tangential approach to the stricture site is often used. When a needle-knife is used, it is difficult to perform coaxial dilation from a tangential approach ([Fig. 2 b]); this technique has caused anastomotic perforation [5] and so is not considered optimal. We therefore use a 6-Fr Cysto-Gastro-Set for the endoscopic dilation of anastomotic strictures ([Fig. 2 a]), which facilitates dilation along the same axis as the guidewire [5]. Our results suggest that a 6-Fr wire-guided diathermic dilator may be useful for anastomotic dilation in patients with severe hepaticojejunostomy strictures.

Fig. 2 a A wire-guided diathermic dilator can easily be used to perform coaxial dilation from a tangential approach. b The needle-knife, and therefore the direction of electroincision, cannot always be aligned exactly along the axis of the guidewire.

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• References

• 1 Yamauchi H, Kida M, Okuwaki K et al. Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy. World J Gastroenterol 2013; 19: 1728-1735
• 2 Shimatani M, Matsushita M, Takaoka M et al. Effective “short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy 2009; 41: 849-854
• 3 Shah RJ, Smolkin M, Yen R et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy. Gastrointest Endosc 2013; 77: 593-600
• 4 Mönkemüller K, Jovanovic I. Endoscopic and retrograde cholangiographic appearance of hepaticojejunostomy strictures: a practical classification. World J Gastrointest Endosc 2011; 3: 213-219
• 5 Kawakami H, Kuwatani M, Kawakubo K et al. Transpapillary dilation of refractory severe biliary stricture or main pancreatic duct by using a wire-guided diathermic dilator (with video). Gastrointest Endosc 2014; 79: 338-343