ESU-guided hepatical gastrostomy and anti-grade cholangioscopy, a novel approach in diagnosis and treatment of biliary obstruction in patients with surgically altered anatomy. Background. Treating patients with obstructive jaundice and surgically altered anatomy presents significant challenges with the traditional endoscopy due to access difficulties and a lack of adequate equipment and tools. Conventional approaches include enteroscopy-assisted ERCP, percutaneous biliary drainage, and surgical biliary diversion. These methods are associated with lower technical success, higher periprocedural risk, prolonged hospital stay, and reduced quality of life. In addition, establishing a diagnosis of recurrent jaundice in these patients may be very challenging. We present a novel method of diagnosis and treatment of biliary strictures in patients with surgically altered intestinal anatomy. Our case. We have a 58-year-old male with a past medical history of cholangiocarcinoma, followed by a right hepatectomy and a rowing wide biliary bypass, presented with new onset painless jaundice and puritis. The symptoms are remarkable for ALP of 516, AST of 155, ALT of 159, and a total bili of 3.8. As you can see in the MRI in figure 1, it revealed an intrahepatic biliary dilatation within the left hepatic lobe. As you can see in figure 2, there's a transition point at the hepatical jejunostomy anastomosis. Our initial attempt for a single balloon-assisted ERCP was not successful because we were not able to access the hepatical jejunostomy. This was due to the length of the efferent limb and significant looping. Our next attempt is with a ESU-guided biliary access. Here you can see we use a 19-gauge needle to access the left hepatic duct. Contrast is injected. And a cholangiogram is used to confirm that we successfully access the left hepatic duct. We were also able to visualize the anastomotic stricture. You can also note that small amount of contrast flowing out of the hepatojejunal anastomosis into the jejunum. Over the same wire, we dilated the hepatical gastrostomy track using a 4-millimeter dilation balloon. Over that same wire, we placed the fully covered, self-expandable metal stent with anti-migration fin properties. We then dilated the stent using the same balloon dilator to anchor the stent into the hepatical gastrostomy. One-month follow-up, status post-hepatogastrostomy stent placement, which allowed for maturation of the anastomosis. You can see here total bili is now down-trending, as well as AST and ALT. There is also significant clinical improvement. We now schedule the patient for follow-up elective cholangioscopy through the now-mature hepatogastrostomy track. This will allow us direct access to the hepatical jejunal anastomotic stricture, which will enable us to evaluate, accurately diagnose, and attain targeted biopsies for further analysis. We engage by going through the cover stent and advance the wire all the way down into the jejunum, which we confirm on repeat cholangiogram. Using a 4-millimeter balloon, we dilate the hepatical jejunal anastomotic stricture. You can appreciate here how narrow the actual stricture is. Here you see inflation of the balloon. It's completely dilated. Then we pull the cover stent over the wire using a snare, now using the same wire as access to perform the cholangioscopy through the now-matured formed hepatogastrostomy track. Initially, you can see the liver parenchyma, where we gain entry into the left hepatic duct. And using the wire as our guide, we advance the cholangioscope all the way to the hepatojejunal anastomosis and into the jejunum. Here you can see the hepatojejunal anastomosis. We confirm on X-ray that we have access. We use the rest of the wire as guidance for us to go into the jejunum to confirm that we are in the appropriate position. You can see here the cholangioscope now in the jejunum. Then we slowly retract the cholangioscope back through the hepatojejunal anastomosis. You can appreciate the friable appearance, the ulceration, and the increased vascular architecture, which is really concerning for recurrence of the cholangiocarcinoma. Using forceps that go through the cholangioscopy, we take biopsies of the anastomosis itself to confirm or to rule out reoccurrence of the cholangiocarcinoma. After that, we retract our cholangioscope back through the bile ducts and through the liver parenchyma into the stomach, and we leave the wire behind. This will serve as a guide for placement of additional biliary stents, of which we place two pigtail plastic stents that will help with further drainage. At the same time, keep the hepatogastrostomy track open. Here in this last image, we can appreciate the two stents through the hepatogastrostomy track. Clinical Implications of the Case. ESU-guided approach for cholangioscopic diagnosis and treatment of obstructive jaundice expands the role of a hepatogastrostomy beyond a palliative method for malignant biliary obstruction. Conclusion. ESU-guided hepatogastrostomy with antigrade cholangioscopy is a novel method for diagnosing and treating biliary strictures in patients with altered anatomy. Hepatogastrostomy serves as a conduit for cholangioscopy, enabling direct visualization of the biliary tree. Selective cannulation of anastomotic strictures, endoscopic, electrohydraulic, lithotripsy, and forceps-directed biopsies. This expands the role of hepatogastrostomy beyond a palliative method for treatment of malignant biliary obstruction. Of note, the absence of percutaneous drainage catheters and surgical incisions combined with the outpatient nature of this procedure makes it a viable option for many patients.

hepatogastrostomy

biliary obstruction

cholangioscopy

surgically altered anatomy

minimally invasive