Cholangioscopy and double-balloon enteroscopy mediated "sandwich puncture" of a completely closed choledochojejunostomy.

Video 1Percutaneous cholangioscopy was performed to confirm complete closure of the choledochojejunostomy. Percutaneous cholangioscopy revealed complete closure of the anastomosis. Our attempt to pass a guidewire through the anastomosis failed accordingly.

Background

Postoperative stricture after choledochojejunostomy is usually treated by (1) a percutaneous transhepatic approach, (2) balloon-assisted enteroscopy, or (3) interventional EUS. However, if the anastomosis is completely closed, it cannot be endoscopically expanded and must be surgically reopened. Although blind puncture and magnetic compression have been proposed as nonsurgical alternatives, they are not yet common procedures, and both carry risks such as perforation and major bleeding.

Here we report the case of a patient with a completely closed choledochojejunostomy that was successfully recanalized by sandwiching the anastomosis between percutaneous cholangioscopy and balloon-assisted enteroscopy devices.

Case

A 37-year-old woman had undergone extrahepatic bile duct resection and biliary reconstruction for congenital biliary dilation. Four months later, she developed cholangitis as a result of stenosis of the choledochojejunostomy. Despite improvement in the cholangitis achieved with percutaneous transhepatic biliary drainage (PTBD), cholangiography via the PTBD catheter revealed no contrast material in the jejunum, and enteroscopy subsequently confirmed complete closure of the anastomosis (Fig. 1). Reoperation was advised, but the patient refused surgery and was referred to our hospital for endoscopic treatment (Video 1, available online at www.VideoGIE.org).

Figure 1

Cholangiogram obtained through the percutaneous transhepatic biliary drainage catheter. Two percutaneous transhepatic biliary drainage catheters were inserted for biliary drainage at the previous hospital. The first catheter was inserted from the left hepatic duct, and another was added from the branch of B3 because of poor drainage. Contrast agent was injected through the catheter, but the jejunum did not become visible. The yellow arrow shows the original location of the choledochojejunostomy.

Initial approach

Percutaneous cholangioscopy (SPY-DS; Boston Scientific Corp, Boston, Mass, USA) confirmed that the cholangiojejunostomy was completed occluded; our attempt to pass a guidewire (Visiglide2; Olympus Medical Corporation, Tokyo, Japan) through the anastomosis failed accordingly (Fig. 2).

Figure 2

The anastomosis scar (yellow arrow), as revealed by the cholangioscopy through the branch of B3.

Treatment

The anastomosis scar was observable from both the bile duct and the jejunum sides. Therefore, dilation was attempted by puncturing the duct in the location of the scar while it was sandwiched between percutaneous cholangioscopy and balloon-assisted enteroscopy (EI-580BT; Fujifilm Corp, Tokyo, Japan), which is the latest version of the short-type double-balloon enteroscope that has a 1.55-m working length and a wider 3.2-mm working channel. The anastomosis scar was sufficiently thin for the lights of the 2 endoscopes to be visible on both sides of the bile duct and jejunum.

Fluoroscopy revealed a short distance between the 2 endoscopes (Fig. 3). The puncture point was revealed by the lights of the endoscopes and was marked (a slight indentation) using the tail-tip of the guidewire from the bile duct side (Fig. 4). After confirmation that the guidewire was visible from the jejunal side, the tail-tip of the guidewire was used to puncture the mucosa in the direction of the jejunum (Fig. 5).

Figure 3

X-ray image showing the short distance between the cholangioscope and enteroscope and revealing that the scar is sufficiently thin to allow for puncture.

Figure 4

The tail-tip of the guidewire, visible under the mucosa of the jejunum (yellow arrow), was slightly pushed from the bile duct side to determine the puncture point and then pushed farther so that it became visible from the jejunal side.

Figure 5

The tail-tip of the guidewire was used to puncture the scar, from the bile duct side into the jejunum (enteroscopic view), by moving it toward the light of the enteroscope.

A cautery dilator (fine025; Medico’s Hirata Inc, Osaka, Japan) was then advanced from the jejunum to the bile duct to cover the guidewire, which protruded into the jejunum (Fig. 6). The dilator was easily passed through the anastomosis scar without energization. After a second guidewire was placed from the jejunal side into the bile duct, the fistula was dilated to 4 mm with a balloon dilator (REN; Kaneka Corp, Tokyo, Japan) (Fig. 7).

Figure 6

The cautery dilator was advanced over the guidewire from the jejunum into the bile duct (cholangioscopic view). The yellow arrow shows the tip of the cautery dilator.

Figure 7

Balloon dilation of the newly developed fistula using a 4-mm-diameter balloon dilator (enteroscopic view).

Finally, a 10- to 40-mm fully covered self-expandable metal stent (FCSEMS) (BONASTENT M-intraductal; Standard Sci Tech, Seoul, South Korea) was placed in the fistula through the balloon-assisted enteroscope (Fig. 8). Fluoroscopy showed successful opening of the FCSEMS within the newly developed fistula (Fig. 9). The PTBD catheter (7F balloon; Create Medic Co Ltd, Tokyo, Japan) was kept in place in case the FCSEMS did not function.

Figure 8

The fully covered self-expandable metal stent deployed in the fistula (enteroscopic view).

Figure 9

X-ray image showing that the fully covered self-expandable metal stent (yellow arrow) placed within the fistula can be opened sufficiently for drainage of bile into the jejunum. Contrast medium injected from the percutaneous transhepatic biliary drainage catheter easily flows into the jejunum.

Postoperative course

Because neither jaundice nor cholangitis developed, the PTBD catheter was removed 1 month after treatment; the FCSEMS was removed via enteroscopy 6 months after treatment. One year after removal of the FCSEMS, no adverse events have occurred.

Conclusions

For the treatment of postoperative anastomotic closure, the sandwich puncture, in which the anastomosis scar is viewed from the bile duct and jejunum sides using a cholangioscope and an enteroscope and is then punctured, may be a safe method that avoids reoperation. One of several advantages is that sandwich puncture can be performed while the condition and thickness of the anastomosis are being determined.

Disclosure

Dr Fujisawa receives lecture fees from Boston Scientific Corporation. Dr Isayama receives research grants from Boston Scientific Corporation and Fujifilm Corporation. All other authors disclosed no financial relationships.