Closure of bilioenteric anastomotic dehiscence using a thru-the-scope endoscopic TAC and suture system. These are our disclosures. Pancreaticoduodenectomy may be complicated by hepaticojejunal anastomotic bile leaks. Early bile leaks are managed surgically, but delayed repair is impaired by adhesions and peritonitis requiring endoscopic or radiologic intervention. ERCP and altered upper GI anatomy may preclude the use of typical accessories. Endoscopic suturing using low-profile helical TACs has been successfully used to close luminal defects, but application to bilioenteric anastomosis has not yet been explored. Here we present the case of a 63-year-old male with a history of an apulary neuroendocrine tumor status post-wibble procedure. Course has been complicated by a recurrent bile leak status post-open repair of an early pancreaticojejunal and hepaticojejunal anastomotic dehiscence. Initial ERCP noted a 1cm defect at the hepaticojejunal anastomosis that was bridged with an 8mm by 4cm fully covered self-expandable metal stent, as well as a double pigtail stent. ERCP is now repeated, noting a progressively enlarging dehiscence. The defect is closed using a TAC-based endoscopic suturing method. The metal stent and pigtail are removed to expose the field. Active bile leak can be seen into a 1cm defect at the anastomosis containing a surgical drain. APC was used to ablate the tissue margin around the anastomosis to induce granulation. The first helical TAC was affixed to the exposed common hepatic duct and deployed. We continued to apply additional endoscopic TACs in a running fashion along the distal common hepatic duct as well as the perianastomotic jejunum. You can see gradual apposition of the tissue with closure of the defect. In total, three sets of four endoscopic TACs were deployed. Tension was applied to the 3-O polypropylene sutures, which were then fixed using a knotless cinch device. Following closure, the hepatic duct could be easily cannulated, contrast was injected confirming no ongoing extravasation. The site was reassessed at three weeks, healthy appearing granulation tissue was seen, and the hepatic jejunostomy appeared patent. A diminutive residual defect was seen at the lateral margin of the anastomosis. A fourth set of four endoscopic TACs was successfully applied to fully close the dehiscence and to reinforce the anastomosis. Endoscopy was repeated giving concerns for possible mild ongoing bile leak. Upon close inspection, the anastomosis appeared entirely intact. A 10mm by 4cm fully covered self-expandable metal stent was deployed across the anastomosis to divert bile flow. Bile leak gradually resolved and the surgical drains were removed. On six month follow up, the metal stent had spontaneously migrated out and was no longer seen on cross-sectional imaging. The patient remained asymptomatic without clinical or radiographic evidence of recurrent bile leak. Persistent bile leak secondary to anastomotic dehiscence may occur despite placement of a fully covered metal stent. Closure of anastomotic dehiscence with hemostatic clips may be impractical and ineffective. Similarly, standard and illuminal suturing using a gastroscope may not be possible in the setting of altered anatomy. Through-the-scope tack and suture systems compatible with colonoscopes offer another avenue for tissue apposition and defect closure. In conclusion, through-the-scope endoscopic suturing using a low-profile helical tacking system can be a viable and minimally invasive means of repairing bileoenteric anastomotic dehiscence in the case of altered post-surgical anatomy.

closure

bilioenteric anastomotic dehiscence

through-the-scope endoscopic tacking

suturing system

pancreaticoduodenectomy