EUS directed Enteroenterostomy ERCP, or ED-E, for the management of recurrent cholangitis. Advances in the surgical management of gastrointestinal disease have led to a rise in the number of patients with altered anatomy. As ERCP remains the paramount tool in the management of pancreatic obiliary disease, this rise represents a growing challenge for endoscopists. Success rates of ERCP in altered anatomy have been estimated to be as low as 55%, with morbidity as high as 20%. Established options for pancreatic obiliary access include percutaneous interventions, balloon-assisted or long-limb ERCP, or EUS-directed interventions, including EUS-directed transgastric ERCP in patients with Roux-en-Y gastric bypass, or EUS-guided hepaticogastrostomy, or EUS choledochoduodenostomy, in select patients with obstructions or strictures. Reports of EUS-directed enteroenterostomy ERCP, or ED-E, are limited, but may represent a new therapeutic modality. We present a case of a 41-year-old female with Roux-en-Y choledochodegenostomy with recurrent cholangitis, managed through an EUS-directed enteroenterostomy ERCP. The patient presented to an outside facility with right upper quadrant abdominal pain and fever to 103 degrees Fahrenheit. She had a past medical history of chronic hepatitis B and a past surgical history of a cholecystectomy in 2005, complicated by bile duct injury, requiring Roux-en-Y choledochodegenostomy at the time of the insult. CT imaging at the outside hospital demonstrated pneumobilia along with intra- and extrahepatic duct dilation. Edema was noted in the porta hepatis suggestive of possible cholangitis, and a loop of bowel could be seen in the right upper quadrant corresponding to her history. Labs demonstrated a cholestatic liver injury with a conjugated hyperbilirubinemia. The patient was initiated with antibiotics and transferred to our facility for further management. On arrival, she reported similar episodes of abdominal pain over the past 15 years and reported a remote history of a SCOPE procedure that was unsuccessful. A discussion regarding the potential treatment options were held. Percutaneous transhepatic cholangiography was considered. However, we first favored an attempt at internal endoscopic management, and the patient did not wish to have any external drains. A neuroscopy-assisted ERCP was considered. However, we elected against this given the patient's high pre-procedural probability for requiring complex biliary intervention. We eventually elected to pursue EUS-directed enteroenterostomy ERCP. EUS-directed enteroenterostomy ERCP involves the deployment of a lumen-opposing metal stent from the proximal GI tract to the afferent enteral limb, facilitating direct access to the pancreatic obiliary anastomoses. For the purpose of LAMS puncture, the afferent limb has historically been distended through a percutaneous transhepatic catheter, or direct infusion from deep balloon enteroscopy. However, EUS-guided direct puncture from the proximal GI tract with afferent limb infusion offers a streamlined endoscopic approach. On review of her initial imaging, it became apparent she was a good candidate for ED-E as her duodenal bulb, seen in the red arrow, appeared to be in proximity with what appeared to be her afferent enteral loop, seen in the blue arrow, which led to her bile ducts. EUS revealed a dilated biliary bifurcation adjacent to a loop of bowel, believed to be the afferent limb. Using a 19-gauge needle, the loop of bowel was punctured using a transduodenal approach. The loop was then distended with a solution of sterile water and dye, and fluoroscopy confirmed distension of the afferent enteral limb. There was no retrograde filling of the biliary tree, suggesting ongoing biliary obstruction. A 20mm x 10mm electrocautery-enhanced lumen-opposing metal stent was then used to puncture the afferent loop under sonographic guidance opposite the biliary anastomosis. Bile-tinged fluid rapidly emerged following LAM's deployment. The waist of the stent was then dilated to 20mm. Despite puncture from the duodenal bulb, the proximal phalange deployed transpyloric. In our experience, this may occur in the setting of a short duodenal bulb, however, spontaneous migration into the duodenum is expected in the ensuing 1-2 days. Given her hemodynamic stability, we elected not to perform single-session ED-E. She clinically improved with antibiotics, and her liver chemistries declined. Given her stability, she was discharged with a course of oral antibiotics and planned for ERCP in 10 days. On follow-up, a therapeutic gastroscope was advanced and the LAM's was now noted to be in the duodenal bulb. Here, a near-complete anastomotic stricture was visualized. Wire-guided cannulation was successfully achieved. Phalangeogram demonstrated a 12mm stricture. This was subsequently dilated using an 8mm wire-guided dilated balloon. Rapid evacuation of bile was seen following dilation, and balloon sweeps resulted in the removal of small sludge and debris. The lumen-opposing middle stent was left in place, and plans were made for repeat ERCP in 3 weeks. On follow-up exam, there was a recurrence of the stricture requiring repeat balloon dilation to 10mm. Following dilation, the bifurcation was seen in close proximity to the coledocojejunostomy. A decision was made to leave the lumen-opposing middle stent in place and assess her clinical response over the ensuing 3 months. On outpatient follow-up, the patient has remained symptom-free following her last-stage ED-E procedure. She is tolerating a regular diet and is planned for a repeat ERCP in 3 months with further management to be determined at that time. Technique Highlights Biliary access was successfully achieved via the creation of an enteroenterostomy using a purely endoscopic approach. Freehand EUS access of the jejunum was achieved in the altered anatomy state from the duodenum. Transpyloric deployment of lumen-opposing middle stent did not result in gastric outlet obstruction and spontaneous migration of the proximal flange was observed. LAMS access facilitated the use of a standard therapeutic endoscope allowing for the full use of biliary accessories. Repeat intervention was easily able to be performed due to the ease of access. Advances in biliary access techniques are necessary to meet the growing challenges facing therapeutic endoscopists. To our knowledge, this is the first reported case of a freehand transpyloric EUS-directed enteroenterostomy ERCP performed. While traditional methods of performing ERCP in patients with altered anatomy have poor rates of success, newer techniques such as EUS-directed enteroenterostomy ERCP offer a greater opportunity for optimal management. Our case supports the use of EUS-directed enteroenterostomy ERCP as a safe and effective endoscopic option in appropriate patients.

cholangitis

EUS-directed enteroenterostomy ERCP

altered anatomy

Roux-en-Y choledochodegenostomy

EUS-guided direct puncture