A novel endoscopic technique using fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy: the saddle-cross technique (with video)

Novel Biliary Stent Insertion via Percutaneous Trans-jejunal Approach for Liver Remnant Preservation After Extended Right Hepatectomy

Extended right hepatectomy (ERH) for hilar cholangiocarcinoma (HCCA) is a complex procedure associated with a high risk of postoperative complications. We present a case of ERH complicated by a biliary fistula at the hepatico-jejunostomy site, which led to a severe anastomotic stricture. Traditional percutaneous transhepatic drainage repeatedly failed in this case. The stricture was ultimately treated with trans-jejunal metal stent insertion, successfully restoring bilio-enteric drainage. A 62-year-old male patient was diagnosed with HCCA. After staging, he underwent liver vein deprivation to augment the future liver remnant (FLR), followed by curative resection via ERH (segments I and IV-VIII). Postoperatively, a bile leak at the anastomotic site resulted in a bilio-cutaneous fistula. While conservative management led to a gradual resolution, the fistula caused a tight anastomotic stricture, leading to obstructive jaundice. Traditional percutaneous transhepatic drainage attempts repeatedly failed to traverse the lengthy stricture. Consequently, a novel procedure of inserting a metal biliary stent via a percutaneous puncture of the jejunal loop was attempted. Under CT guidance, the Roux loop was catheterized and distended with contrast, and a guidewire was positioned inside. The patient was then transferred to the angiography suite. Under fluoroscopy, a transjugular intrahepatic portosystemic shunt needle punctured the bile duct stump, providing access to the Roux loop. A fully covered metal stent was successfully deployed crossing the anastomosis re-establishing bilio-enteric drainage. This novel radiological intervention salvaged the remnant liver when standard approaches had failed. Hepatico-jejunostomy stricture following ERH is a critical postoperative complication that can severely compromise FLR function. Surgical options in such cases are limited and pose significant risks. Radiological intervention offers a promising alternative, enabling effective drainage even in the most challenging postoperative scenarios.

Cannulation of pancreaticojejunostomy anastomosis with a novel controllable catheter

Anastomotic stenosis of hepaticojejunostomy and pancreaticojejunostomy are common adverse events after pancreaticoduodenectomy. Kuraoka and colleagues describe their method of cannulating the bile and pancreatic ducts using a novel catheter with a controllable tip, which is useful when it is difficult to align the axis of the forceps port and the anastomosis.

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.

Study protocol for a prospective, multicentre, phase II trial on endoscopic treatment using two fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy

INTRODUCTION

The current endoscopic treatment for postoperative benign hepaticojejunostomy anastomotic stricture (HJAS) has a high technical success rate and is highly effective in the short term. However, long-term results have shown a high rate of stenosis recurrence, which indicates an insufficient response to treatment. Three prospective studies on fully covered self-expandable metallic stent (FC-SEMS) treatment for benign HJAS used the stenosis resolution rate as the primary endpoint, and no study has yet used the long-term non-stenosis rate (at 12 months) as the primary endpoint.

METHODS AND ANALYSIS

We launched the 'saddle-cross study', which will be conducted as a multicentre, prospective intervention of endoscopic treatment using two modified FC-SEMSs (BONASTENT️ M-Intraductal) that have been improved for benign stenosis in patients with benign HJAS, with the long-term non-restenosis rate (at 12 months) as the primary endpoint. This study aims to evaluate the long-term non-restenosis rate (at 12 months) and safety of the saddle-cross technique for benign HJAS. We plan to enrol 50 participants.

ETHICS AND DISSEMINATION

This study has been approved by the Certified Review Board of the National Cancer Center, Japan (CRB3180009). The results will be reported at various conferences and published in international peer-reviewed journals.