Endoscopic ultrasound-guided salvage for a disconnected choledochojejunostomy anastomosis through a jejunal stoma

A 25-year-old man with a history of deceased-donor liver transplantation using a right lobe graft with Roux-en-Y choledochojejunostomy was referred for endoscopic management of cholangitis due to anastomotic strictures [1] ([Fig. 1]). The patient developed postoperative bile leakage and disconnection of the choledochojejunostomy anastomosis. He underwent percutaneous transhepatic placement of catheters for the bile ducts in segments 5, 6, and 7 (B5 – 7). Re-canalization was achieved by percutaneous procedures for B5 and B6, whereas a complete disconnection between B7 and the jejunum was not amenable to the percutaneous approach or double-balloon endoscopy. Therefore, we decided to perform endoscopic ultrasound (EUS)-guided drainage to re-anastomose B7 with the jejunum.

Fig. 1 Fluoroscopic image suggesting a complete disconnection between the jejunum and the bile duct at segment 7 (arrows) in a patient with a history of Roux-en-Y choledochojejunostomy.

We inserted an echoendoscope (EG580UT; Fujifilm Corp., Tokyo, Japan) through a pre-existing jejunal stoma, after dilating the fistula with a 20-mm balloon catheter. With the help of contrast injection through the biliary catheter, B7 was punctured using a 19-gauge needle and a 0.025-inch guidewire was passed through the fistula of a percutaneous catheter. After inserting a balloon catheter over the guidewire with external traction, we dilated the puncture site and deployed a 10-Fr percutaneous catheter into the jejunum across B7 ([Fig. 2]).

Fig. 2 Radiographic images during endoscopic ultrasound-guided biliary drainage showing: a a guidewire passed through the fistula of a percutaneous catheter; b balloon dilation of the puncture site.

In the following session, we inserted a forward-viewing endoscope (GIF-2T240; Olympus Medical, Tokyo, Japan) through the stoma and replaced each of the percutaneous catheters with fully-covered self-expandable metal stents (8 mm × 4 cm; BONASTENT M-Intraductal; Sewoon Medical Co., Ltd., Chungcheongnam-do, South Korea) ([Fig. 3]) [2]. The metal stents were subsequently removed endoscopically 3 months later, with no recurrence of cholangitis ([Fig. 4]).

Fig. 3 Radiographic image showing three fully-covered self-expandable metal stents placed endoscopically into the three biliary branches.

Fig. 4 Endoscopic image suggesting that the choledochojejunostomy anastomosis was widely open after removal of the self-expandable metal stents.

EUS-guided biliary drainage for a complicated anastomotic disconnection was feasible through a jejunal stoma ([Video 1]). Given recent advances in EUS-guided pancreatobiliary interventions [3] [4], the use of a jejunal stoma as a port for endoscopic biliary access could further expand this developing frontier of non-surgical management for postoperative complications [5].

Video 1 Endoscopic ultrasound-guided choledochojejunostomy for an anastomotic disconnection in a patient with a history of Roux-en-Y choledochojejunostomy. Three self-expandable metal stents are inserted. After their removal 3 months later, the choledochojejunostomy anastomosis is left widely open.

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• References

• 1 Tsujino T, Isayama H, Kogure H. et al. Endoscopic management of biliary strictures after living donor liver transplantation. Clin J Gastroenterol 2017; 10: 297-311
• 2 Moon JH, Choi HJ, Koo HC. et al. Feasibility of placing a modified fully covered self-expandable metal stent above the papilla to minimize stent-induced bile duct injury in patients with refractory benign biliary strictures (with videos). Gastrointest Endosc 2012; 75: 1080-1085
• 3 Nakai Y, Isayama H, Yamamoto N. et al. Indications for endoscopic ultrasonography (EUS)-guided biliary intervention: Does EUS always come after failed endoscopic retrograde cholangiopancreatography?. Dig Endosc 2017; 29: 218-225
• 4 Teoh AYB, Dhir V, Kida M. et al. Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel. Gut 2018; 67: 1209-1228
• 5 Hu B, Sun B, Cai Q. et al. Asia-Pacific consensus guidelines for endoscopic management of benign biliary strictures. Gastrointest Endosc 2017; 86: 44-58