EUS guided management of post-surgical injury using lamps in patients with biliary tract strictures. These are our disclosures. Therapy of post-surgical biliary strictures may be challenging. Stenosis calibration is usually performed with plastic or fully covered self-expandable metal stents. Luminoposy metal stents are a newly available therapeutic alternative for first-line and rescue therapy in post-surgical biliary tract strictures. Two young adult females who underwent a complicated open cholecystectomy, secondary to acute calculus cholecystitis, presented with a post-surgical biliary tract stricture injury. We performed EUS guided first-line and rescue therapy using lamps. A 25-year-old female with a past surgical history of a complicated open cholecystectomy who required vital digestive anastomosis. Two months later, she required intraoperative hepatical jejunostomy. A month later, she developed jaundice, pruritus, right upper quadrant abdominal pain, and nausea. The abdominal CT reported intra and extra hepatic dilation. And her lab work displayed a cholestatic pattern. We performed an EUS guided antigrade drainage using lamps as a first-line therapy in this post-surgical hepatico-jejunal stricture. Complete anastomosis obstruction was confirmed with a cholangiogram. First, with a 19-gauge needle, we accessed the left intrahepatic biliary duct. Then, the common bile duct was accessed with a 19-gauge needle. A wire guide was used to secure the path. We used a 10 by 10 millimeter lamps with an electrocardiogram enhanced delivery system. It was placed at the vital digestive anastomosis site, and its expansion was performed using a 10 millimeter balloon catheter. Finally, for stricture calibration, an 8 French by 5 centimeter plastic double pigtail stent was deployed through the lamps. This procedure was successfully performed under endosonographic and fluoroscopic guidance with no reported periprocedural complications. A 24-hour upper endoscopy showed no evidence of inactive bleeding, and lamp's permeability was confirmed. CT scan confirmed absence of leaks and the lamp's correct position. At her one-week follow-up, her total and direct bilirubin levels had exponentially decreased. Currently, the patient remains stable. A 24-year-old female with a past surgical history of laparoscopic cholecystectomy converted into an open cholecystectomy presented with jaundice, fever, abdominal pain, and nausea three days post-procedure. Her lab work exhibited a cholestatic pattern. Post-surgical ERCP showed a complete common bile duct dissection and absence of anastomosis. Intraoperative bilodigestive anastomosis was not performed in this patient. An EUS-guided hepaticoduodenostomy was performed in this patient. We placed a 10-by-10-millimeter lamps with an electrocautery-enhanced livery system, and a 10-french-by-10-centimeter double-peak tail plastic stent was deployed through the lamps under endosonographic and fluoroscopic guidance. The patient was admitted for conservative management for presenting post-procedural fever and abdominal pain. She was discharged 48 hours later. Absence of leaks and proper lamps positioning was confirmed with a CT scan. A clinically relevant decrease of the direct and total bilirubin levels was reported at the three-week follow-up. Ten months later after this procedure, the patient remains stable. Diastolic strictures and recurrent cholangitis are possible long-term complications post-biodigestive anastomosis, increasing morbidity and deteriorating the quality of life. Limited information on the role of EUS-guided bivalenturic anastomosis in post-surgical etiologies is currently available, as most data is from malignancy-related etiologies. When feasible, EUS-guided management of post-surgical injury using lamps as a first-line or rescue therapy may be a novel, safe, and effective alternative for patients with iatrogenic biliary trichostrictures. However, large case series and prospective cohorts are required to evaluate this technique in clinical practice.

EUS-guided management

lamps

biliary tract strictures

cholecystectomy complications

bilirubin levels improvement