Lumen-apposing metal stent for the creation of an endoscopic duodenojejunostomy to facilitate bile duct clearance following Roux-en-Y hepaticojejunostomy

A 52-year-old woman with history of bile duct injury following cholecystectomy and previous Roux-en-Y hepaticojejunostomy was admitted because of cholangitis. Her work-up revealed a 7-mm stone in the right intrahepatic duct on magnetic resonance cholangiopancreatography (MRCP). An initial single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) revealed independent right and left hepaticojejunostomies and bilateral strictures. A large right intrahepatic filling defect was identified on an occlusion cholangiogram ([Fig. 1]). Bilateral dilation of the anastomosis was performed with an 8-mm hydrostatic balloon, but the stone could not be removed and two plastic biliary stents (7 F × 5 cm) were placed.

Fig. 1 Occlusion cholangiogram during enteroscopy-assisted endoscopic retrograde cholangiopancreatography showing a large right intrahepatic filling defect.

Contrast injection into the biliopancreatic limb showed that it was closely approximated to the duodenal bulb and therefore suitable for an endoscopic ultrasound (EUS)-guided duodenojejunostomy (EUS-DJ) to facilitate access to the afferent limb and complete clearance of the bile duct using the appropriate accessories. A single-balloon enteroscope fitted with a cap was advanced to the hepaticojejunostomy. The afferent limb was filled with diluted contrast mixed with 1 % methylene blue, and 2 mg of glucagon was given intravenously to slow peristalsis. A linear echoendoscope was then advanced to the duodenal bulb and the distended jejunal limb was identified and punctured using a 19-gauge fine-needle aspiration (FNA) needle. Aspiration of blue-tinged fluid confirmed the correct location in the afferent limb. A cautery-enhanced lumen-apposing metal stent (LAMS; 15 mm × 10 mm) was deployed, thereby creating a duodenojejunostomy ([Video 1]).

Video 1 Endoscopic ultrasound-guided duodenojejunostomy in a patient with a Roux-en-Y hepaticojejunostomy and right intrahepatic duct stone.

The patient returned 4 weeks after the procedure for an ERCP with cholangioscopy. A therapeutic upper gastrointestinal endoscope was advanced to the duodenojejunostomy ([Fig. 2 a]) and the hepaticojejunostomy was identified 1 – 2 cm distally ([Fig. 2 b]). A digital single-operator cholangioscope was advanced into the right anterior, mid, and posterior branches of the right intrahepatic duct. Sludge but no stones were seen in the posterior branch ([Fig. 3]). The left intrahepatic duct was normal. The patient underwent a further MRCP and a follow-up ERCP after 4 weeks with no additional stones identified ([Fig. 4]), and the LAMS was removed. To date, the patient has remained asymptomatic.

Fig. 2 Endoscopic views showing: a the patent duodenojejunostomy lumen-apposing metal stent; b the independent right/left hepaticojejunostomy.

Fig. 3 Digital cholangioscopic view showing no evidence of persisting intraductal stones.

Fig. 4 Cholangiographic view during follow-up endoscopic retrograde cholangiopancreatography performed through the duodenojejunostomy. showing no residual right or left intrahepatic stones.

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