Hepaticojejunostomy Stricture Research Articles

Transluminal antegrade drill dilation technique for hepaticojejunostomy stricture with cholangioscopic evaluation (with video).

Background and study aims Balloon dilation and plastic stent deployment have been performed as hepaticojejunostomy stricture (HJS) treatment techniques under endoscopic ultrasound guidance (EUS). Although these techniques have shown favorable clinical results, the treatment period can be long because stent deployment is required. In addition, HJS may recur even after treatment because the scar tissue itself remains. To overcome these challenges, we developed an EUS-guided antegrade drill dilation technique for treating HJS. The aim of this study was to evaluate the technical feasibility and safety of this technique in terms of the pre- and post-cholangioscopic findings. Patients and methods This retrospective study included consecutive patients whose conditions were complicated with symptomatic HJS between November 2022 and February 2023. Transluminal antegrade drill dilation (TAD) using a novel drill dilator was attempted within 14 days after EUS-guided hepaticogastrostomy (HGS). HJS was diagnosed with cholangioscopy before TAD, and resolution was evaluated after TAD using cholangioscopy. Results TAD was attempted at approximately 11 days after EUS-HGS. The cholangioscope was inserted successfully in all patients after this procedure. Cholangioscopy revealed stricture without evidence of malignancy in 19 patients. In the remaining three patients, stricture was not observed and these patients underwent stent exchange rather than TAD. Among the 19 patients, passage of the guidewire across the HJS into the intestine was unsuccessful in four patients, and the technical success rate for this procedure was 78.9%. TAD was successful in all 15 patients in whom passage of the guidewire was achieved. Conclusions In conclusion, TAD appears to be technically feasible and safe.

Endoscopic ultrasound-guided antegrade dilation using a drill dilator for hepaticojejunostomy stricture with cholangioscopic findings.

Endoscopic ultrasound-guided antegrade dilation using a drill dilator for hepaticojejunostomy stricture with cholangioscopic findings.

Outcome assessment of biliary stricture repair following cholecystectomy in a tertiary care centre.

Bile duct injuries (BDIs) are the potential grievous complications of cholecystectomy that result in substantial morbidity and mortality. Outcomes of BDI management depend on multiple factors such as the type and extent of injury, timing of repair, and surgical expertise. The present retrospective study was conducted to analyse the risk factors associated with the BDI repair outcomes. The data of patients having primary or recurrent bile duct stricture following BDI from 1985 to 2018 were retrospectively evaluated. A total of 268 patients underwent hepaticojejunostomy (HJ). Of the total, 218 patients had primary bile duct stricture, and 50 patients had HJ stricture. The most commonly performed procedure for primary BDI was Roux-en-Y HJ (RYHJ), followed by right hepatectomy, right posterior sectionectomy, and left hepatectomy. All patients with strictured HJ underwent RYHJ, except one who underwent a right hepatectomy. Outcome assessment using the McDonald grading system showed that 62%, 27%, 5%, and 6% of patients with primary bile duct stricture had grade A, grade B, grade C, and grade D complications, respectively, with a mortality rate of 3.21%, whereas 46%, 34%, and 18% patients with strictured HJ had grade A, grade B, and grade C complications, respectively, with a mortality rate of 2%. High-up biliary strictures, early repair, and blood loss > 350mL are the surrogate markers for failure of repair. Management of BDI needs a multidisciplinary approach. The outcomes of both primary biliary stricture and strictured HJ can be improved with management of patients in a tertiary care centre. However, attempts to repair within 2weeks of injury, Strasberg E4 and E5, and blood loss of > 350mL may have an adverse effect on the outcome of HJ.

The Utility of Biliary Manometry in Assessing Early Catheter Removal After Percutaneous Balloon Dilatation of Hepaticojejunostomy Strictures.

Background and objectivePercutaneous balloon dilatation followed by long-term internal-external biliary catheter (IEBC) placement is the standard radiological management for postoperative hepaticojejunostomy (HJ) strictures. The treatment is considered successful when cholangiography shows a free flow of contrast across the anastomosis and the patient passes a "clinical test". However, these tests may not be suitable predictors of long-term successful treatment outcomes. The purpose of this study was to assess the utility of biliary manometry in the evaluation of successful treatment outcomes after HJ stricture dilatation and IEBC placement and its efficacy as a tool for early catheter removal.Patients and methodsA total of 14 patients underwent percutaneous balloon dilatation of HJ strictures with IEBC placement. A two-to-three-month interval was maintained between sessions of exchanging or upsizing IEBCs. Biliary manometry was performed after a mean duration of 6.3 months. Intra-biliary pressure of <15 mmHg was considered as the success threshold.ResultsAmong the 14 patients, 11 patients passed initial manometry and had their IEBCs removed and were followed up for a mean duration of 47.8 months. Of these, one patient developed biliary obstruction after six months and underwent repeat HJ stricture dilatation and long-term IEBC placement. Three patients failed manometry and underwent re-dilatation of HJ strictures with IEBC placement. Using Kaplan-Meier survival analysis, the probability of patients remaining stricture-free after HJ stricture dilatation was found to be 100% at three months and 91% at six, 12, 18, 24, 36, and 47.8 months.ConclusionBiliary manometry prevents subjective variations in determining treatment endpoints and helps to assess early catheter removal after percutaneous balloon dilatation of HJ strictures.

Лечение поздней стриктуры гепатикоеюнального анастомоза после постхолецис­тэкто­ми­чес­кого повреждения желчного пузыря

Hepaticojejunostomy stricture is the disastrous complication of biliary surgery, if untreated can lead to intrahepatic stones, recurrent cholangitis, biliary cirrhosis and hepatic faiulure. Here, we report a case with the one-more year history of recurrent cholangitis, caused by late stricture of hepaticojejunal anastomosis after iatrogenic bile duct injury

New Biomarker Affecting the Prevalence of Hepaticojejunostomy Stricture in the Treatment of Bile Duct Injury

Objectives: To determine the relationship between preoperative neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) with the prevalence of hepaticojejunostomy stricture in patients operated for bile duct injury repair. Material and methods: From a prospectively collected data base of patients with diagnosis of bile duct injury, we selected those that had a Roux-en-Y hepaticojejunostomy. We collected demographics as well as preoperative and postoperative laboratory values. We run binary logistic regression to estimate the risk for developing anastomosis stricture for each variable. Results: 118 patients were included, 84 women (71.2%) and 34 men (28.8%). Mean age of patients was 41.7 years. Other demographics did not prove different between groups. The univariate analysis Exp(B) was 1.112 (p=0.032) for NLR, 1.004 (p=0.019) for PLR, 0.34 (p=0.047) for HPB surgeon and 1.219 (p=0.6) for high injury. The multivariate analysis Exp(B) was 1.016 (p=0.819) for NLR, 1.005 (p=0.031) for PLR, 0.25 (p=0.026) for HPB surgeon and 2.28 (p=0.067) for high injury Conclusions: NLR and PLR has been found to be potential markers of subclinical inflammation and in uni and multivariate analysis shows some promising power to predict the risk of hepaticojejunostomy stricture. Neutrophil to lymphocyte ratio showed a direct association with hepaticojejunostomy stricture development, statistically not significant. A high platelet-to-lymphocyte ratio showed a statistically significant association with the development of a stricture, on a multivariate analysis. Also a reconstruction done by a hepatopancreatobiliary surgeon showed a protective association for the development of stricture, statistically significant.Tabled 1Multivariate logistic regressionVariableBWaldExp(B)IC 95%pAge0.0070.1791.0070.9731.0430.672Gender (female)-0.6271.6240.5340.2041.4010.203Surgeon (HPB)-1.3874.9860.250.0740.8440.026*BDI repair (early)-0.4820.9420.6180.2331.6340.332Reintervention (No)-0.3040.4660.7380.3081.7670.495Type of BDI (near confluence)0.8263.3652.2850.9455.5260.067NLR0.0160.0531.0160.8881.1620.819PLR0.0054.661.00511.010.031* Open table in a new tab

Multimodal Approach to Acquired Bronchobiliary Fistula Secondary to Hepaticojejunostomy Stricture Following Yttruim-90 Therapy

Introduction: Bronchobiliary fistula (BBF) is an abnormal connection between the bronchial system and biliary tree. Bilioptysis (bilious-tinged sputum) is pathognomic of BBF. Mortality rate of BBF is as high as 12.7%. Method: A 56-year-old male who presented with stage IV pancreatic neuroendocrine tumor, underwent pancreaticoduodenectomy with partial hepatectomy, followed by Yttrium-90, and microwave ablation. Surveillance imaging, 2.5 years later, noted increase in hepatic lesions. Additional Yttrium-90 was poorly tolerated and patient was referred for peptide receptor radionuclide therapy. Ten months later patient presented with abdominal pain, cough with yellow-tinged sputum and history of recurrent pneumonia. Imaging demonstrated intrahepatic biliary dilation, peri-hepatic abscess and right-sided pleural effusion. Results: Patient underwent percutaneous drainage of abscess and chest tube placement. Persistent cough and sputum production prompted evaluation with HIDA (hepatobiliary iminodiacetic acid) and bronchoscopy, confirming BBF. Cholescintigraphy with single-photon emission computed tomography (NM-SPECT) localized the fistula tract to the right upper lobe of liver (Figure-1). Initially attempted biliary decompression with percutaneous transhepatic cholangiogram was unsuccessful due to failed cannulation of the hepaticojejunostomy, indicating complete stenosis at the anastomosis. Finally, the patient underwent resection of the hepaticojejunostomy with mobilization of the pancreaticobiliary limb and Kasai-type porto-enteric anastomosis between the pancreaticobiliary limb and hepatic duct. Complete resolution of symptoms and the bronchopulmonary fistula on follow up imaging, was noted. Conclusion: BBFs are rare, misdiagnosed, and difficult to treat. Although treatment with minimally invasive approach has favorable results, history of previous biliary reconstruction, may warrant multimodal treatments including percutaneous and complex surgical intervention.

Delay in Resection of Choledochal Cysts Highlights the Significance of Malignancy Potential: A Case Report

Risks of choledochal cysts include obstructive jaundice, cholangitis, and malignancy. Therefore, cysts are typically resected especially if symptomatic. A 69 year old female who presented with cholangitis due to a common bile duct stone. Past medical history significant for type III choledochal cyst and recurrent cholangitis. Previous surgical interventions included biliary bypass at age 10 and revision in early 20s; choledochal cyst was not resected at either surgery. Imaging suggested hepaticojejunostomy stricture leading to recurrent cholangitis. Initially patient was very hesitant to undergo any further surgical intervention and opted for close surveillance. Shortly after patient develop rigors and while still reluctant to undergo large procedure did consent to choledochal cyst resection and hepaticojejunostomy revision. During the operation, choledochal cyst identified, mobilized and approximately 80% of it was excised. Hepaticojejunostomy appeared to incorporate remnant gallbladder based on intraoperative evaluation. Cholangiogram was attempted through duct of Luschka but was not completed due to difficult angle and subsequently ligated. New hepaticojejunostomy was created using original roux limb and good biliary drainage of right and left hepatic lobes demonstrated on completion cholangiogram. Final pathology significant for poorly differentiated adenocarcinoma, biliary type in choledochal cyst and remnant gallbladder; additionally bile duct margin showed invasive adenocarcinoma. Patient then underwent a completion pancreaticoduodenectomy with partial hepatectomy for complete oncologic resection. In adults presenting with a symptomatic choledochal cyst, excision should be recommended treatment. Risk of malignancy is present in biliary tree despite resection. Thus, the entire biliary tree should be inspected for multiple areas of neoplasm.

Percutaneous Balloon Dilatation for Hepaticojejunostomy Stricture Following Paediatric Liver Transplantation: Long-Term Results of an Institutional "Three-Session" Protocol.

The aim of this study was to report the long-term results of an institutional protocol of percutaneous biliary balloon dilatation (PBBD) on paediatric patients with benign anastomotic stricture after liver transplantation. As a secondary objective, we evaluated risk factors associated with post-treatment re-stricture. Fourteen paediatric, post-liver transplant patients with benign anastomotic stricture of Roux-en-Y hepaticojejunostomy were included. All patients underwent the same treatment protocol of three PBBD procedures with 15-day intervals. Clinical outcome was analysed using the Terblanche classification. Primary patency rate was assessed with the Kaplan-Meier test. All patients had an initial successful result (Terblanche grade, excellent/good) after PBBD. At the end of the follow-up time of 35.7 ± 21.1months (CI95%, 23.5-47.9), 10 patients persisted with excellent/good grading, while the remaining 4 had re-stricture, all of the latter occurring within the first 19months. Patency rate after percutaneous treatment at 1, 3, and 5years were 85.7%, 70%, and 70%, respectively. History of major complication after liver transplantation was associated with 5 times higher risk of re-stricture, HR 5.48 [95% CI, 2.18-8.78], p = 0.018. In paediatric patients with benign anastomotic stricture of hepaticojejunostomy after liver transplantation, the "Three-session" percutaneous biliary balloon dilatation protocol is associated with a high rate of long-term success. In this limited series, the history of post-liver transplant major complication, defined as complications requiring a reintervention under general anaesthesia or advanced life support, seems to be an independent risk factor for stricture recurrence.

Transluminal intrahepatic bile duct stone removal using a novel spiral basket catheter via the endoscopic ultrasound-guided hepaticogastrostomy route (with video).

Recently, endoscopic ultrasound (EUS)-guided biliary drainage has been developed as an alternative biliary drainage technique for failed endoscopic retrograde cholangiopancreatography (ERCP) or inaccessible papilla. Among the various EUS-guided biliary drainage procedures, EUS-guided hepaticogastrostomy (HGS) can be performed in patients with surgically altered anatomy. More recently, various transluminal treatments have been described after EUS-HGS, such as antegrade stone removal. In patients with hepaticojejunostomy strictures, stone extraction into the intestine might be challenging even after performing hepaticojejunostomy stricture dilation using a balloon catheter. In such cases, transluminal stone removal is considered an alternative method. With transluminal stone removal, a small stone that escapes from the conventional basket or from a balloon catheter could migrate into the branch bile ducts. The novel spiral basket catheter available in Japan. The wires form a helix shape, wherein each wire is wound counterclockwise, and the winding pitch becomes gradually tighter from the proximal portion to the tip. As the winding pitch is smaller and the wires are in closer contact with the bile duct wall as compared with conventional basket catheter, small bile duct stones can be easily captured by simply pulling back the catheter while the basket is open. In addition, even during withdrawal inside the bile duct, a high retrieval performance is assured by the special design that maintains the opening width on the top end. Therefore, transluminal stone removal using this novel basket catheter might be clinically useful, although further prospective evaluation of a larger number of cases is needed.

Laparoscopic management of post pancreaticoduodenectomy benign hepaticojejunostomy stricture: A case report

Hepaticojejunostomy (HJ) stricture following pancreaticoduodenectomy (PD), though rare, can have serious consequences as they can present with recurrent cholangitis. Percutaneous interventional procedures are the usual first line treatment options but have high re-stricture rates and require multiple sittings. We present a case of 64 year old gentleman who underwent open PD for ampullary adenocarcinoma in 2010 and received 6 cycles of adjuvant chemotherapy. He had recurrent attacks of cholangitis since June 2019 and was managed initially with medical therapy. He was diagnosed to have a stricture of HJ with multiple stones in the biliary system proximally. After failed conservative therapy, the patient was subjected to laparoscopic revision of HJ. After adhesiolysis, the previous HJ was dismantled, ducts cleared off stones and an end to side HJ was done using PDS 3-0 sutures. The total operating time was 165 minutes and the total blood loss was about 100 mL. The patient developed fever on post-operative day (POD) 2 and was managed with antibiotics. He was discharged on POD 6. He has been on follow-up for more than three months now and has been asymptomatic. Laparoscopic revision of HJ stricture following PD appears to be feasible with good outcome when performed by an experienced hepatobiliary surgeon. Long term follow-up is needed before firm conclusions can be drawn.

Treatment Methods for Different Variations Syndrome Mirizzi

The number of patients with complicated forms of cholelithiasis of cholelithiasis is progressively growing. One of the complications of gallstone disease is Mirizzi syndrome (SM). The reason for the development of which is the spread of the inflammatory - destructive process from the gallbladder to the bile ducts with the formation of pressure ulcers in the common bile duct, as a result of which the formation of a cholecystobiliary fistula occurs, through which stones from the gallbladder enter the main bile ducts. The analysis of the surgical treatment of patients with cholelithiasis (GSD) treated in the UH NJSC "MUS" was carried out. There were 3842 patients in total, Patients were in the period from January 2012. to July 2018 The analysis revealed that of all these patients with gallstones, Mirizzi SM type III and IV syndrome was diagnosed in 25 (0.7%). In 14 (56%) patients with type III SM and type IV SM, 11 (44%). The main group consisted of 10 (40%) patients and 15 (60%) patients included in the control group. The main group completed: 1) In type III SM (only 4 (40%) patients). One patient underwent hepaticojejunostomy according to the clinic method (2017/0423.1). In 3 patients, cholecystohepaticocholedochoplasty was performed with U-shaped interrupted sutures on the drainage according to Vishnevsky (2017 / 0980.1); 2) In type IV SM (a total of 6 (60%) patients). 4 patients underwent hepaticojejunostomy according to the clinic method (2017/0423.1). In 2 patients, cholecystohepaticocholedochoplasty was performed with U-shaped interrupted sutures on the drainage according to Vishnevsky (2017 / 0980.1). The developed and tested methods of surgical treatment of Mirizzi syndrome of types III and IV make it possible to improve the immediate and long-term results of surgical treatment of patients with this pathology. These methods of surgical treatment allow preserving the physiology of the bile outflow without postoperative complications typical for traditional hepaticojejunostomy (incompetence of the anastomotic sutures, stricture of hepaticojejunostomy).

EUS-guided hepaticogastrostomy for management of cholangitis, hepatolithiasis, and anastomotic stricture after Roux-en-Y hepaticojejunostomy.

Video 1EUS-guided hepaticogastrostomy for management of cholangitis, hepatolithiasis, and anastomotic stricture after Roux-en-Y hepaticojejunostomy.

EUS-guided hepaticogastrostomy for hepaticojejunostomy stricture using a 22G needle and a mechanical dilator (withvideo).

EUS-guided biliary drainage (EUS-BD) has been indicated for benign biliary strictures. However, the intrahepatic bile duct is sometimes much narrower in benign biliary strictures. In this situation, puncture of the intrahepatic bile duct using a 19-G needle is sometimes challenging. Several reports have described attempts at EUS-BD using a 22-G needle, but fistula dilation with a 22-G needle is challenging because the 0.018-inch guidewire is not stiff enough to perform dilatation. Recently, a thin mechanical dilator has become available. After its insertion into the biliary tract, the 0.018-inch guidewire can be replaced with a 0.025-inch guidewire. We herein describe the technical procedure of EUS-guided hepaticogastrostomy using a 22-G needle with a thin mechanical dilator.

Gallstone ileus after hepaticojejunostomy in liver transplant recipient: case report

Presenter: Patricio Vanerio MD | Hospital Central de las Fuerzas Armadas Background: Gallstone ileus is an infrequent cause of mechanical bowel obstruction. It is caused by transition of a gallstone in the gastrointestinal tract usually through a biliary-enteric fistula, occurring in 1 to 3% of all cases of mechanical bowel obstruction. In patients with a hepaticojejunostomy gallstones can be formed at the proximal side of it and then pass through the lumen. In this cases hepatolithiasis is associated with recurrent anastomotic stricture and cholangitis. Even though abdomen computed tomography (CT) is very informative for diagnosis of gallstone ileus, it is oftenly found during laparotomy performed for unexplained small bowel obstruction. We present the case of a patient who was admitted with a gallstone ileus, in whom the gallstone stone was formed at the hepaticojejunostomy (liver transplant recipient) and entrapped at afferent loop of the Roux-en-Y jejunojejunostomy. Methods: We present the case of a 22yo female. Heretopic reduced liver recipient 20 years ago because of biliary atresia. Admitted 2 years ago with a mild cholangitis, MRCP demonstrated stenosis of hepaticojejunostomy associated with hepatolithiasis. Treatment consisted in percutaneous dilation of bilioenteric anastomosis and progression of litiasis to jejunum. No complications or symptoms were registered during follow up in the next 2 years. Begun with sudden intermittent colicky abdominal pain, nausea, and vomiting. Computed tomography (CT) evidenced small intestine dilation associated with 2 hyperdense structures of about 30 and 40mm as cause of obstruction (figure). Mild intraabdominal fluid, no large intestine dilation, no other pathological findings. Exploratory laparotomy was performed, extensive adhesiolysis, dilation of roux en Y afferent loop, a gallstone of 40mm was the cause of obstruction. A second gallstone was found distally. Enterotomy with gallstone removal was performed. Postoperative occurred without incidents. Patient was discharged at day 3. Results: Intestinal obstruction has many causes, gallstone ileus is infrequent and usually secondary to cholecystoduodenal fistula which is corresponds to an abnormal communication between the gallbladder and the duodenum that occurs as a rare complication of an untreated gallstones. Other cause of gallstone ileus is hepatolihtiasis formed over a pathologic hepaticojejunostomy with anastomotic stricture and recurrent cholangitis. In this cases, the usual complication is a cholangitis secondary to the obstruction and infection of the bile duct. Percutaneous approach consists in stricture dilation and extraction and/or progression of lithiasis, surgery is a more aggressive and morbid approach which consists in hepaticojejunostomy re do. In our patient gallstone ileus was caused by gallstones advanced during percutaneous treatment 2 years before. Clinical and radiological manifestations of small bowel obstruction do not differ. Neither does surgical treatment, in which laparotomy is the most common approach and enterotomy with gallstone extraction is indicated. Conclusion: We present an extremely rare case of gallstone ileus due to hepatolithiasis caused by stricture of hepaticojejunostomy in a liver transplant recipient. Percutaneous treatment was performed to treat bilioenteric stricture, however this procedure progressed lithiasis distally into jejunal loop causing a small bowel obstruction 2 years later.

Multimodal approach to acquired bronchobiliary fistula secondary to hepaticojejunostomy stricture following yttrium-90 therapy

Presenter: Asmita Chopra MD | The University of Toledo Background: Acquired bronchobiliary fistula (BBF) is a rare and challenging complication resulting in an abnormal connection between the bronchial system and biliary tree. It most commonly presents with a pathognomonic productive cough featuring bilious-tinged sputum or “biloptysis”. BBFs can be associated with hepatic abscesses, malignancy and liver directed interventions. They are known to have high mortality rates, in some series up to 12.7%. A patient with development of biliary obstruction and BBF secondary to Y-90 (yttrium-90) radioembolization therapy is presented. Methods: A 56-year-old male presented with stage IV neuroendocrine pancreatic cancer and underwent initial sequential treatments included pancreaticoduodenectomy with partial hepatectomy, Y-90, and liver microwave ablation. Patient did well for 2.5 years at which time he was noted to have an interval increase of hepatic lesions on surveillance imaging. Additional Y-90 was given for the right sided lesions. This was poorly tolerated resulting in significant abdominal pain and failure to thrive and further Y-90 therapy was not pursued. Patient gradually improved and was referred for potential peptide receptor radionuclide therapy. Ten months later patient returned to the HPB Surgery clinic with complaints of persistent abdominal pain, cough with copious amounts of yellow-tinged sputum and history of multiple bouts of pneumonia. Imaging demonstrated intrahepatic biliary dilation, a right-sided peri-hepatic abscess and right-sided pleural effusion. Right hepatic lobe involution with significant left lobe hypertrophy was also noted. Results: Patient subsequently underwent percutaneous drainage of abscess and chest tube placement for effusion. However, his cough and sputum production persisted, prompting evaluation of an acquired BBF. The diagnosis was confirmed on HIDA (hepatobiliary iminodiacetic acid) and bronchoscopy. Cholescintigraphy with single-photon emission computed tomography (NM spect CT scan) localized the fistula tract to the right upper lobe of the liver near the abscess (Figure 1). Initial treatment focused on biliary decompression with PTC (percutaneous transhepatic cholangiogram) and abscess drain placement. During the procedure, attempts at cannulating the hepaticojejunostomy were unsuccessful, indicating complete stenosis at the anastomosis. Finally, the patient underwent elective surgery to restore biliary enteric continuity. This involved resection of the hepaticojejunostomy with mobilization of the pancreaticobiliary (PB) limb and Kasai-type porto-enteric anastomosis between the PB and hepatic duct at the previously placed PTC drain entrance site. Complete resolution of the bronchopulmonary fistula was demonstrated during subsequent biliary drain exchange following surgery and patient doing well greater than 4 years after initial cancer diagnosis. Conclusion: BBFs are rare, misdiagnosed, and difficult to treat. Although treatment has shifted toward less invasive approaches with favorable results, in the setting of previous biliary reconstruction these fistulas pose unique challenges. Multimodal treatments including advanced percutaneous and complex surgical intervention may be required to rescue these patients.

Endoscopic ultrasound-guided hepaticogastrostomy for hepaticojejunostomy stricture using a one-step stent deployment technique (with video).

Highlight A novel, fully covered, self-expandable metal stent with a fine-gauge stent delivery system has recently become available in Japan. Ogura and colleagues describe the technical procedure of endoscopic ultrasound-guided hepaticogastrostomy using a one-step stent deployment technique without fistula dilation, which is clinically useful and may help prevent adverse events.

Transluminal antegrade biopsy using a novel forceps biopsy device for hepaticojejunostomy stricture.

Transluminal antegrade biopsy using a novel forceps biopsy device for hepaticojejunostomy stricture.

S2330 Altered Anatomy ERCP Using a Novel Dynamic Rigidizing Overtube

INTRODUCTION: Biliary stone removal is challenging in patients with surgically altered anatomy. Double Balloon Enteroscopy (DBE) has been used to assist ERCP with cannulation, but it is often difficult and channel size is suboptimal for ERCP equipment. Antegrade EUS-guided techniques can sometimes be used but it can be challenging with higher risk. A novel dynamic rigidizing overtube is now available to help complete colonoscopy in a difficult looping colon. Normally the overtube is completely pliable, but when a vacuum is applied it becomes 15 times more rigid, providing stability and preventing looping. In this case, we use this novel overtube to complete a complex ERCP in a patient with altered anatomy. CASE DESCRIPTION/METHODS: This is a 42-year-old female with a history of iatrogenic bile duct transection during cholecystectomy who underwent Roux-en-Y Hepaticojejunostomy (HJ). Her course was complicated by HJ stricture requiring balloon-assisted enteroscopy with ERCP to place a fully-covered metal stent. After 3 months the stent was removed, but restricturing occurred 6 months later and she developed left-sided intrahepatic stone disease. Double balloon enteroscopy to reach the anastomosis became more difficult. As a result, multiple antegrade procedures via EUS placed Hepaticogastrostomy with lithotripsy were used to treat accessible intrahepatic stones, but several more remained. To facilitate further endoscopic procedures, a shortcut was made using laparoscopic revision to create a new entero-enterostomy from the proximal jejunum to the pancreaticobiliary (PB) limb. Repeat enteroscopy with a slim colonoscope failed to enter the PB limb despite multiple attempts due to difficult angulation and looping in the stomach. A dynamic rigidizing overtube was then used to assist with enteroscopy to reach the HJ. The rigidizing overtube, placed over the colonoscope, allowed the scope to advance to the HJ without looping in the stomach and provided improved control up the ascending PB limb. The colonoscope then deployed a stone extraction balloon to remove biliary duct stones. Cholangiogram confirmed stone removal and bile duct clearance. DISCUSSION: This case demonstrates the use of a rigidizing overtube to prevent looping and assist with complex stone removal via ERCP in altered anatomy. Such a device may be useful in other altered anatomy ERCP cases when anterograde approaches fail and a luminal approach is required.Figure 1.: Demonstration of rigidizing overtube. Overtube is advanced over colonoscope to its hub. Normally it is flexible, providing for normal movement during endoscopy. When a vacuum is applied it allows 1 to 1 movement, providing stability and reducing looping.Figure 2.: Stone removal with visible filling defect distal to injected contrast. Stone was removed using an extraction balloon via colonoscope and clearance was confirmed with a repeat cholangiogram.

Optimal timing for surgical reconstruction of bile duct injury: meta-analysis.

BackgroundMajor bile duct injury (BDI) after cholecystectomy generally requires surgical reconstruction by means of hepaticojejunostomy. However, there is controversy regarding the optimal timing of surgical reconstruction.MethodsA systematic review was performed by searching PubMed, Embase and Cochrane databases for studies published between 1990 and 2018 reporting on the timing of hepaticojejunostomy for BDI (PROSPERO registration CRD42018106611). The main outcomes were postoperative morbidity, postoperative mortality and anastomotic stricture. When individual patient data were available, time intervals of these studies were attuned to render these comparable with other studies. Data for comparable time intervals were pooled using a random‐effects model. In addition, data for all included studies were pooled using a generalized linear model.ResultsSome 21 studies were included, representing 2484 patients. In these studies, 15 different time intervals were used. Eight studies used the time intervals of less than 14 days (early), 14 days to 6 weeks (intermediate) and more than 6 weeks (delayed). Meta‐analysis revealed a higher risk of postoperative morbidity in the intermediate interval (early versus intermediate: risk ratio (RR) 0·73, 95 per cent c.i. 0·54 to 0·98; intermediate versus delayed: RR 1·50, 1·16 to 1·93). Stricture rate was lowest in the delayed interval group (intermediate versus delayed: RR 1·53, 1·07 to 2·20). Postoperative mortality did not differ within time intervals. The additional analysis demonstrated increased odds of postoperative morbidity for reconstruction between 2 and 6 weeks, and decreased odds of anastomotic stricture for delayed reconstruction.ConclusionThis meta‐analysis found that surgical reconstruction of BDI between 2 and 6 weeks should be avoided as this was associated with higher risk of postoperative morbidity and hepaticojejunostomy stricture.