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Patients with altered anatomy create an endoscopic challenge when physicians attempt to access the biliary tree because the papilla often is not accessible by conventional endoscopic tools. Novel approaches with EUS have provided innovative methods to therapeutically treat biliary tract disease.
Case
We present the case of a 69-year-old woman who had previously undergone a Billroth II procedure with conversion to a Roux-en-Y reconstruction because of persistent nausea, vomiting, and weight loss, along with concern for failure to thrive. She presented to another facility for evaluation, and during the diagnostic workup, CT of the abdomen and pelvis with contrast material demonstrated evidence of cholelithiasis and choledocholithiasis. The patient did not have signs or symptoms of cholangitis. Notably, she was a Jehovah’s Witness and refused any blood products. Her prior surgical records were obtained, and they indicated that her Roux limb was approximately 75 cm long. She was otherwise healthy without any other cardiopulmonary comorbidities and did not take anti-inflammatory agents or blood thinners.
A push enteroscopy was attempted to perform ERCP by retrograde inspection of the pancreatobiliary limb, but the jejunojejunal anastomosis was not found. The decision was made to pursue a hepaticogastrostomy for biliary access (Video 1, available online at www.VideoGIE.org).
Procedure
The creation of a hepaticogastrostomy took place in 2 stages.
In stage 1, EUS was used to identify the hepatic ducts, and the left hepatic duct was targeted (Figs. 1 and 2). An access needle allowed advancement of the wire into the duodenum. Injection of contrast material confirmed evidence of choledocholithiasis (Fig. 3). A dilating catheter and then a dilating balloon provided access to the hepatic duct for placement of a stent. A fully covered metal stent was placed into the hepatic duct, creating a hepaticogastrostomy (Fig. 4). A double-pigtail stent was placed across the metal stent to anchor it in place (Fig. 5).
Figure 1Targeting of the hepatic duct through EUS.
Figure 5Fluoroscopic depiction of fully covered metal stent placement with anchoring double-pigtail plastic stent for creation of the hepaticogastrostomy.
In stage 2, the plastic stent was removed. A balloon sphincteroplasty was performed across the papilla by use of an 8-mm biliary balloon. Antegrade and retrograde extraction of stones was performed with an extraction balloon (Fig. 6). The metal stent was removed.
Figure 6Fluoroscopic depiction of a balloon sweep.
The patient was followed up by our surgical colleagues and experienced measurable improvement in her symptoms. She, notably, did not have any adverse events related to her previous endoscopic procedure, including post-ERCP pancreatitis and bleeding. She was referred for a cholecystectomy. A follow-up CT scan before her surgery showed clearance of her choledocholithiasis (Fig. 7).
Figure 7Follow-up CT scan showing clearance of the patient’s choledocholithiasis.
Our patient did not have any surgical options and was not a candidate for an EUS-directed transgastric ERCP, given her subtotal gastrectomy. Percutaneous approaches were not attempted, given the need for short-term external drainage after the procedure. In patients with altered anatomy, where accessing the native papilla is difficult, a hepaticogastrostomy provides an efficient, minimally invasive endoscopic option for the treatment of biliary lithiasis. Additionally, balloon sphincteroplasty without sphincterotomy is a safe method to facilitate antegrade extraction of stones.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
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