EUS-directed transenteric ERCP-assisted internalization of a percutaneous biliary drain in Roux-en-Y hepatico-jejunostomy anatomy. Co-authors and relevant disclosures are as seen here. ERCP is often technically challenging in patients with post-surgical upper GI anatomy. Disclosures such as enteroscopy-guided ERCP and EUS-guided hepatogastrostomy can facilitate biliary access in some patients with surgical anatomy, but their rate of success in patients with Roux-en-Y anatomy is often limited, especially in patients who have undergone total gastrectomy or liver transplantation. We present a case of EUS-directed transenteric ERCP, or EDEE, a novel procedure to facilitate biliary access and intervention in non-gastric bypass Roux-en-Y anatomy. In this procedure, patients with Roux-en-Y anatomy undergo EUS-guided placement of a lumen-opposing metal stent extending from the stomach or duodenum to the afferent jejunal limb. This then facilitates passage of a therapeutic endoscope into the afferent limb where biliary access can be attained. Our case is that of a 24-year-old female with biliary atresia who underwent liver transplantation with creation of a Roux-en-Y hepatico-jejunostomy. She presented to our facility with fever and direct hyperbilirubinemia concerning for acute cholangitis. She subsequently had an MRCP that demonstrated dilated intrahepatic ducts. Endoscope-assisted ERCP was attempted, but this was technically unsuccessful due to tortuosity of the afferent jejunal limb. The patient subsequently underwent placement of a percutaneous transhepatic biliary drain. A cholangiogram at that time showed delayed drainage of contrast from the biliary tree and a tight hepatico-jejunostomy stricture shown here in red. A percutaneous biliary drain was placed as shown here in yellow with resolution of the patient's cholangitis symptoms. A staged internalization of the percutaneous biliary drain was then planned using the EDEE approach beginning with creation of a gastrojejunostomy. After fluoroscopy, contrast was injected through the percutaneous biliary catheter shown here with the red arrow to opacify the afferent limb of the jejunal jejunostomy shown here with the yellow arrow. A corresponding loop of small bowel was identified under EUS and punctured with an FNA needle shown in red. Dilute contrast injection showed opacification of the afferent jejunal limb, which was then punctured with a 15 mm electrocautery-enhanced lumen-opposing metal stent, and the stent deployed as shown here in red. The deployed stent was then examined, revealing the internalized portion of the biliary drain in the afferent jejunal limb. The patient returned three weeks later for ERCP through the newly formed gastrojejunostomy tract. A therapeutic endoscope was advanced into the stomach to reveal the patent gastrojejunostomy lumen-opposing metal stent. Initial attempts to pass the scope through the stent were met with resistance. The intact stent was therefore removed using grasping forceps. The scope, however, was still unable to traverse the mature gastrojejunostomy tract. The tract was therefore dilated with a 15 mm balloon. This facilitated passage of the scope into the afferent jejunal limb, where the internalized portion of the biliary drain and hepatico-jejunostomy were visualized. The biliary drain was then removed percutaneously, and the hepatico-jejunostomy cannulated using a guide wire. The subsequent cholangiogram demonstrates a 10 mm common hepatic duct indicated by the yellow arrow. The hepatico-jejunostomy was then dilated with a 10 mm balloon. A 10 French by 5 cm straight plastic biliary stent was then placed in the common hepatic duct, and this was followed by a side-by-side 7 French by 5 cm plastic stent. The intact lumen-opposing metal stent was then backloaded into the instrument channel of the scope and replaced across the gastrojejunostomy. A final fluoroscopy image shows positioning of the two side-by-side biliary stents indicated by the yellow arrow and the gastrojejunostomy stent shown in red. The patient returned for a follow-up ERCP at three months. The hepatico-jejunostomy anastomosis was visualized with both plastic biliary stents in place. These were then removed to reveal a widely patent hepatico-jejunostomy. A subsequent cholangiogram demonstrates mild residual narrowing of the hepatico-jejunostomy but brisk drainage of contrast from the biliary tree, as demonstrated by the two red arrows. Shown in yellow is a plastic double pigtail stent left across the gastrojejunostomy to maintain patency in the event repeat intervention was needed. Six months later, the patient represented with abdominal pain and diarrhea. An upper endoscopy was performed, revealing friable gastric mucosa, suggestive of bile gastritis. As the patient's liver function tests had remained within normal limits and the patient free of cholangitis symptoms, the decision was made to remove the plastic double pigtail stent and close the gastrojejunostomy using a 12-6 over-the-scope clip. In conclusion, we demonstrate that EDEE can facilitate safe and reliable biliary access in patients with Roux-en-Y anatomy through creation of an EUS-directed gastroenteric or enteroenteric fistula. Our case also demonstrates two important features of the procedure. One is that EDEE requires direct access to the afferent jejunal limb, such as a percutaneous biliary drain, for contrast opacification and distention. Gastroenteroscopy creation also increases gastric bile exposure and can lead to bile gastritis, as was the case in our patient. The gastrojejunostomy tract should therefore be closed once no longer needed.

EUS-directed transenteric ERCP

biliary access

Roux-en-Y anatomy

lumen-opposing metal stent

biliary system