Su1296 STEP WISE ANTEGRADE TREATMENT FOR HEPATICOJEJUNOSTOMY ANASTOMOTIC STRICTURE VIA EUS GUIDED HEPATICOGASTROSTOMY

Abstract

Treatment of Hepaticojejunostomy (HJ) anastomotic stricture is always challenging. Current treatment such as enteroscopy-assisted ERCP is not always successful and might not be suitable for repeated endoscopic dilation. EUS guided hepaticogastrostomy (EUS HGS) is now an alternative biliary drainage method for benign biliary stricture but the treatment approach of this technique is still not well established. We retrospectively studied 7 patients with post-surgery HJ stricture who received EUS HGS approach after failed balloon-assisted enteroscopic drainage. In all cases, connection between left and right intrahepatic bile duct were confirmed by CT scan to ensure the maximal benefit of EUS HGS. Initial EUS HGS was performed using fully covered metallic stent (SEMS) 10x100 mm in 6 cases and 6x100 mm in one case. After tract maturation, SEMS were removed and anastomotic area was cannulated through the EUS HGS fistula. The anastomosis was dilated and multiple 7fr double pigtail plastic stents were placed from the jejunum to the stomach lumen across the stricture site (figure 1). The stents were exchanged every 2-4 months and lithotripsy was performed through HGS in case with intrahepatic duct stone following the treatment protocol (figure 2). The median age was 43 (32 -81). Overall 9 EUS HGS procedures were successfully performed in 7 patients. Stent migration occur in one patient who received 6x100 mm stent placement and in another patient who loss to follow up. In later cases, only 10x100 mm SEMS were used and SEMS were fixed to the stomach using hemoclips. During the subsequent procedure, cannulation across the stricture was performed using balloon occluded cholangiogram, rotatable sphincterotome or direct cholangioscope. HJ was successfully cannulated in the second procedure in 6 patients and we experienced one case of failed cannulation due to severe stricture and intrahepatic bile duct stone. No migration was seen after plastic stent placement. HJ stricture improved in cases that the HJ could be cannulated (6/7 patients) and all patients achieve complete biliary drainage. Complication included mild cholangitis after EUS HGS in all cases which was treated only by antibiotics. Median follow up time was 8.5 months (range 4-30 months). Antegrade treatment for HJ stricture via EUS HGS should be performed in step wise fashion. Migration after initial metallic stent placement is common so stent fixation and stent exchange to plastic stent should be followed after tract maturation.Flow chart demonstrate step wise treatment for hepaticojejunostomy strictureView Large Image Figure ViewerDownload Hi-res image Download (PPT)