Enteroscopy-assisted ERCP with needle-knife strictuoplasty of hepatical jejunostomy. Co-authors include Kaushik Das and Vladimir Kushner. Dr. Weaver, Dr. Das, and Dr. Kushner have no relevant relationships with industry to disclose. Patients with surgically-altered pancreaticobiliary anatomy with long limb bypass, such as in Roux-en-Y gastric bypass or Whipple resection, pose significant challenges to biliary accumulation. These challenges include identifying the afferent limb, reaching the biliary enteric anastomosis, as well as stenosis and sharp angulation of the biliary enteric anastomosis. Published technical success rates of reaching the biliary enteric anastomosis in surgically-altered pancreaticobiliary anatomy ranges from 64% to 95%. Anastomotic structures are common following biliary enteric anastomosis and occur in 10% of cases. Management of biliary enteric anastomotic structures includes ERCP, percutaneous transphatic biliary drainage, or surgical revision. Published failure rates of endoscopic guidewire passage through a biliary anastomotic structure range from 4% to 38%. This is a case of a 66-year-old female with history of pancreatic cancer who had previously been treated with the Whipple procedure and adjuvant chemotherapy who presented with jaundice and pruritus. A CT scan demonstrated marked intraepatic biliary ductal dilation with transition point at the level of the hepatical jejunostomy, with marked nodular enhancement concerning first stricture, as well as findings suggestive of cholangitis. She was referred for attempt at ERCP. A pediatric colonoscope was advanced to the hepatical jejunostomy, and a guidewire was passed into the biliary tree under fluoroscopic guidance. A needle knife was advanced to the hepatical jejunostomy. A needle knife stricturalplasty was performed, as balloon dilators and a sphincteratome were unable to cross the stricture. Balloon sweeps were performed with removal of stones, pus, and debris. A fully covered metal stent was placed across the stricture. A pediatric colonoscope was used to reach the hepatical jejunostomy, as a regular upper endoscope was unable to reach the anastomosis. Initial endoscopic views demonstrated a severely strictured hepatical jejunostomy. A straight 0.035 inch by 480 centimeter wire was passed into the biliary tree. Subsequently, the balloon-tipped catheter was not able to be advanced through the stricture. Attempts were made to pass a 4 millimeter and 6 millimeter balloon dilator through the stricture, though this was unsuccessful. Attempts were made to pass a sphincteratome through the stricture, though this was also unsuccessful, as the sphincteratome would not pass through the tight stricture. Additional equipment, such as Sohendra push dilators and Sohendra stent extractors, were not used, as they were not long enough to be advanced through the pediatric colonoscope. A needle knife was advanced to the level of the stricture, and using the previously placed wire as a guide, needle knife stricturoplasty was performed successfully at the anastomosis, followed by immediate drainage of a large amount of pus. Care was taken to ensure that the needle knife cut was performed in the proper orientation of the anastomosis, and not towards the free wall, to decrease the risk of perforation. During standard needle knife sphincteratomy, the proper orientation of the cut can be ascertained by identifying the intradenal segment and other usual landmarks. However, in this case, the anatomical landmarks were not available due to the altered anatomy. As such, there was a potential for perforation during stricturoplasty. Techniques to ensure proper needle knife cut in the orientation of the hepaticotriginostomy include using rotatable fluoroscopy, the curvature of the instruments, and injection of contrasts. Finally, had a perforation or microperforation occurred, the plan was to place a covered metal stent with interventional radiology and surgical services on standby if needed. Brushings of the stricture were obtained for cytology, which subsequently returned negative for malignancy. A cholangiogram was obtained and demonstrated a severely dilated common hepatic duct at 13 millimeters and severe dilation of the visualized intrapadic ducts with a focal stricture at the anastomosis. Balloon sweeps were performed with removal of stones, pus, and debris. Subsequently, a 10 millimeter by 4 centimeter fully covered metal stent was placed across the stricture, ensuring that the proximal end of the stent was below the hepatic bifurcation. At follow-up visit with oncology, she was doing well with resolution of her jaundice and paritis, along with improvement in her LFTs. A few months later, the patient was noted to have considerable disease progression, and the decision was made to leave the stent in place. ERCP with needle-knife stricturoplasty can be used in patients with surgically altered pancreatic biliary anatomy with biliary enteric anastomotic stricture in order to gain access to the biliary system and provide biliary decompression.

surgically-altered pancreaticobiliary anatomy

long limb bypass

biliary enteric anastomotic strictures

Whipple procedure

enteroscopy-assisted ERCP