Benign Hepaticojejunostomy Stricture: Not Amenable to Endoscopy/Percutaneous Transhepatic Biliary Drainage—What to do Next?

Abstract

Question: A 41-year-old woman presented with a 1-year history of recurrent cholangitis due to a hepaticojejunostomy (HJ) stricture. Two years earlier, she had undergone laparoscopic cholecystectomy for acute calculus cholecystitis. Her cholecystectomy was complicated by a common bile duct injury which required subsequent HJ. An attempt at endoscopic retrograde cholangiopancreatography using single balloon enteroscopy was unsuccessful in reaching the HJ anastomosis due to sharp jejunal angulation. She then underwent ultrasound-guided percutaneous bile duct access via segment 3 duct and subsequently segment 8. Her cholangiogram showed a tight HJ stricture. Despite multiple attempts, a guide wire could not be negotiated across the stricture (Figure A, B). What should be the next step in management in this case? Is surgery the only option? Look on page 1342 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. She underwent percutaneous ultrasound-guided and fluoroscopic guided puncture of the superficial unfixed jejunal loop proximal to HJ with an 18-G needle (Figure C) and a sheath was placed. With a catheter–guidewire combination, the HJ site was accessed and stricture negotiated. The guidewire was snared through the percutaneous transhepatic biliary drainage access via segment 3 (Figure D). Subsequently, the stricture was dilated through segment 3 with a 10-mm balloon (Figure E). Then, 10-Fr Malecot catheters were placed via segment 3 and segment 8 ducts (Figure F). The patient is now under follow-up and will undergo progressive catheter upsizing via percutaneous transhepatic biliary drainage every 3 months for 1 year. Conventionally, treatment of HJ strictures consists of nonsurgical and surgical methods. Nonsurgical techniques are either by endoscopic1Devière J. Nageshwar Reddy D. Püspök A. et al.Successful management of benign biliary strictures with fully covered self-expanding metal stents.Gastroenterology. 2014; 147: 385-395Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar or percutaneous route using balloon dilatation or stent placement.2Cantwell C.P. Pena C.S. Gervais D.A. et al.Thirty years’ experience with balloon dilation of benign postoperative biliary strictures: long-term outcomes.Radiology. 2008; 249: 1050-1057Crossref PubMed Scopus (55) Google Scholar Surgical methods vary from redo HJ to a number of special techniques such as biliary access loops to facilitate future endoscopic intervention. Fontein et al3Fontein D.B. Gibson R.N. Collier N.A. et al.Two decades of percutaneous transjejunal biliary intervention for benign biliary disease: a review of the intervention nature and complications.Insights Imaging. 2011; 2: 557-565Crossref PubMed Google Scholar previously described success and effectiveness of percutaneous transjejunal biliary intervention for HJ stricture in 63 patients. Six of these patients underwent percutaneous puncture of an unfixed jejunal loop which allowed access through the stricture as in our case. percutaneous transjejunal biliary intervention is technically feasible, safe and can avoid major surgery.