Laparoscopic-assisted transjejunal endoscopic management of intrahepatic calculi and anastomotic stricture in a patient with Roux-en-Y hepaticojejunostomy.

Management of complications in patients with Roux-en-Y reconstruction is still today an important surgical and endoscopic challenge. Various techniques have been employed to manage biliary strictures and intrahepatic calculi in patients with Roux-en-Y hepaticojejunostomy (RYHJ). We report the case of a 24-year-old female who had undergone RYHJ reconstruction 3 years back for choledochal cyst, admitted with the diagnosis of obstructive jaundice due to anastomotic stricture and multiple hepatic duct calculi. She was successfully treated with laparoscopic-assisted transjejunal endoscopic management of intrahepatic calculi and anastomotic stricture, which appears to be safe and useful procedure for anastomotic stricture and hepatic duct calculi in patients with surgically altered anatomy.

INTRODUCTION

The management of complications in patients who undergo surgical procedure resulting in a Roux-en-Y reconstruction is still today an important surgical and endoscopic challenge. Various techniques have been employed to manage biliary strictures and intrahepatic calculi in patients with Roux-en-Y hepaticojejunostomy (RYHJ). The treatment options for intrahepatic calculi and biliary strictures in patients with surgically modified gastrointestinal anatomy include percutaneous transhepatic treatment, peroral short double-balloon enteroscopy, percutaneous transjejunal biliary intervention, laparoscopic-assisted transjejunal endoscopic management (LATEM) and the conventional surgery.[123] Conventional surgery, however, is invasive and technically challenging, and it causes significant morbidity for these patients.

The objective of this report is to present a case of LATEM of intrahepatic duct calculi and anastomotic stricture in a patient with RYHJ, which to the best of our knowledge, is the 11th case reported and the third case of direct access to the hepaticojejunostomy site reported worldwide.[1]

CASE REPORT

We report the case of a 24-year-old female who had undergone RYHJ reconstruction 3 years back for choledochal cyst. She presented to us with episodes of abdominal pain localised in the right upper quadrant, associated with fever, itching and jaundice. Physical examination revealed tenderness on deep palpation in the right hypochondrium, temperature of 101.4°F and heart rate 110 beats/min, with negative peritoneal signs. Laboratory analyses were as follows: haemoglobin 9.8 g%, leucocytes 19.99 × 103/UL, neutrophils 93.8%, total bilirubin 7.28 mg/dl, direct bilirubin 6.37/dl, alanine transaminase 76U/L, aspartate transaminase 95U/L, alkaline phosphatase 571U/L, platelet 247 × 103/μl and international ratio 1.6 and negative viral hepatitis panel. Magnetic resonance cholangiopancreatography revealed bilateral hepatic duct dilatation with multiple calculi with anastomotic stricture [Figure 1].

Figure 1

Magnetic resonance cholangiopancreatography showing hepaticojejunostomy stricture (black arrow) with multiple calculi in the dilated bilateral intrahepatic bile ducts (white arrows)

Owing to the history of RYHJ, we decided to perform LATEM of intrahepatic calculi and anastomotic stricture under general anaesthesia using the standard laparoscopic approach with three trocars. An optical trocar was placed in the midline in between the umbilicus and pubic symphysis and the other two 5-mm trocars at the right and left midclavicular lines just below the umbilicus. The operation began with thorough diagnostic laparoscopy, and after gentle bowel adhesiolysis, the afferent limb, efferent limb and the jejunojejunal (JJ) anastomosis were identified. The right 5-mm port was then extended, and the biliary limb of the jejunum was drawn up to the abdomen. A 1-cm enterotomy was performed on the antimesenteric side of the externalised jejunum, and a side-viewing endoscope (Olympus TJF-Q180V) was inserted into the enterotomy and advanced to the level of the hepaticojejunostomy. A calculus was seen stuck in the anastomotic site which was removed with a biopsy forceps [Figure 2].

Figure 2

A calculus seen stuck in the hepaticojejunostomy site

Under portable C-arm fluoroscopy, the right intrahepatic duct was cannulated and cholangiography was performed, which showed evident dilatation of the right intrahepatic bile ducts with multiple stones [Figure 3]. The anastomotic site was dilated up to 12 mm using wire-guided controlled radial expansion balloon (Boston Scientific) at 3 atmospheric pressure, and cholangiolithiasis was cleared using Dormia basket and a Fogarty balloon catheter. The same was repeated on the left hepatic duct obtaining a subsequent normal cholangiogram. The enterotomy was repaired extracorporeally in double layer, the bowel returned to the abdomen and a non-suction tube drain was inserted into the peritoneal cavity. The post-operative period was uneventful, and the patient was discharged 5 days later.

Figure 3

C-arm fluoroscopic view showing the gastroscope (black arrow) introduced through the anterior abdominal wall and intrahepatic duct cholangiogram showing right intrahepatic bile duct dilatation with multiple stones (white arrows)

DISCUSSION

Bile duct stones are a troublesome post-operative adverse event in patients with a hepatobiliary-pancreatic disease undergoing hepaticojejunostomy such as RYHJ.[2] This can be explained by the direct communication between the biliary and digestive tract owing to the absence of a functional valve such as sphincter of Oddi with the newly formed anastomosis. In addition, there is an increased probability of chyme, bacteria and air entering the biliary tract, as well as the increased levels of mucin and oxygen-free radicals that promote stone formation.[1]

The altered anatomy of RYHJ reconstruction may prove the traditional endoscopic manoeuvre extremely challenging, if not impossible, with standard equipment. The main obstacles are the intubation of the JJ anastomosis, the length of the afferent limb to the JJ anastomosis, the cannulation of the hepaticojejunal anastomotic site and the lack of customised endoscopes and accessories.[4] The new endoscopic approaches such as single or double-balloon enteroscopy is considered as an alternative approach for modified gastrointestinal anatomy patients.[1] Percutaneous transhepatic cholangioscopy (PTC) is another well-described alternative. It can precisely localise the affected bile duct, and it allows repeated interventions through the percutaneous tract. Nonetheless, preparation for a safe and effective PTC may require days or even weeks. In addition, access to multiple bile ducts cannot be achieved in a single puncture. Finally, post-procedural pain requiring analgesic administration has been described as a minor but remarkable disadvantage.[12] Percutaneous transjejunal biliary intervention, a relatively unfamiliar technique, has also shown promising results, although it has yet to be integrated into daily practice.[3] With the development of laparoscopy and clear appearance of its advantages such as lower rates of wound complications, less post-operative pain and early return to normal activity, we decided to use the laparoscopy approach for this procedure. Using laparoscopic-assisted transjejunal endoscopic retrograde cholangiography, we could achieve a minimally invasive procedure to remove stones without the need to expose the patient to the major risks of operation.

Of the ten published cases, eight performed the intervention through the native papilla, whereas two[15] and the present case performed direct cannulation of the hepaticojejunostomy site, as in these patients, hepatic duct could not be reached through the native papilla due to the nature of the previous surgery.

CONCLUSIONS

LATEM of biliary complication is an effective approach in patients with RYHJ and other modified gastrointestinal anatomy. We prefer the transjejunal approach because the jejunum can almost always reach the abdominal wall, and enterotomy can be done extracorporeally hence minimising the peritoneal contamination with the intestinal content. Further studies with a higher number of cases are needed to be able to assess the success rate, morbidity and cost of this new procedure.

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Conflicts of interest

There are no conflicts of interest.