Endoscopic balloon dilatation for benign hepaticojejunostomy anastomotic stricture using short double-balloon enteroscopy in patients with a prior Whipple's procedure: a retrospective study

Study of factors influencing the insertion failure of single balloon enteroscopy-assisted ERCP treatment after bilioenteric Roux-en-Y anastomosis

BACKGROUND AND STUDY AIMS

Fail to reach the bilioenteric anastomosis is the main cause of treatment failure during single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-assisted ERCP) in patients after bilioenteric Roux-en-Y anastomosis. We aim to evaluate factors influencing the endoscopic insertion failure.

PATIENTS AND METHODS

We retrospectively reviewed the clinical data of 231 cases undergoing SBE-assisted ERCP from January 2016 to December 2021. Treatment details and outcomes were studied to analyze the factors involved in endoscopic insertion failure.

RESULTS

The enteroscopy success rate and procedural success rate were 88.3% and 84.4%. Incidence of postoperative adverse events was 3.9%. No serious adverse events occurred. Risk factors of endoscopic insertion failure include first ERCP attempt, side to side anastomosis at the Rou-Y anastomosis, the use of Endo-GIA anastomosis, three bowel lumens seen at the Rou-Y anastomosis under endoscopy, steep angle of the afferent loop at the Rou-Y anastomosis with a U-shape, length of the afferent loop ≥ 50 cm, and twisted afferent loop. Among which the multifactorial analysis suggested that the presence of three bowel lumens at the Rou-Y anastomosis and twisted afferent loop were independent risk factors for enteroscopy failure. For case with twisted afferent loop, the use of a transparent cap with X-ray-assisted guidance during insertion is an effective strategy to improve the success rate.

CONCLUSIONS

SBE-assisted ERCP is safe and effective in patients after bilioenteric Roux-en-Y anastomosis. The severity of afferent loop twisting and Rou-Y anastomosis shape were risk factors for endoscopic insertion failure. Surgeons should take into account the feasibility of postoperative ERCP treatment at the time of operation.

Comparative study of therapeutic outcomes in patients who developed hepatolithiasis after hepaticojejunostomy: balloon-assisted enteroscopic approach versus percutaneous transhepatic approach

BACKGROUND

The treatment of hepatolithiasis in patients who underwent hepaticojejunostomy (HJS) is challenging. In this study, we aimed to clarify the therapeutic outcomes of double balloon enteroscopy (DBE) and percutaneous transhepatic biliary drainage (PTBD) for hepatolithiasis after HJS.

METHODS

Patients who underwent DBE or PTBD for hepatolithiasis after HJS at Hiroshima University Hospital were enrolled, and treatment outcomes and recurrence were compared.

RESULTS

Forty-eight of the 84 eligible patients underwent DBE, with the HJS site reached in 42 patients (87.5%; DBE group). Forty-one patients underwent PTBD (PTBD group). There were no differences in the clinical characteristics and stone-related factors, including localization, maximum diameter, and quantity, between both groups. The complete stone removal rates in the DBE and PTBD groups were 85.7% and 90.2%, respectively. The DBE group had a significantly shorter median length of hospital stay than the PTBD group (6 vs. 21 days, P < 0.001). During a median follow-up of 45 months, stone recurrence was observed in 22 (32.8%) patients. The cumulative recurrence rates at 1, 3, 5, and 10 years were 13.1%, 31.8%, 34.9%, and 52.7%, respectively. The stone recurrence rates of the DBE and PTBD groups were not significantly different (28.6% vs. 37.5%). Multivariate analysis revealed a stone diameter > 8 mm (hazard ratio, 2.602; P = 0.026) and age ≥ 70 years (hazard ratio, 3.077; P = 0.017) as independent risk factors for stone recurrence.

CONCLUSIONS

DBE showed outcomes comparable to those of PTBD in the treatment of hepatolithiasis in patients who underwent HJS. Although reaching the HJS site is difficult in some cases, treatment can be completed within a short period with DBE; therefore, it could be the first choice of treatment for hepatolithiasis after HJS.

Efficacy and long-term outcomes of single-balloon enteroscopy-assisted treatment for biliary obstruction after choledochojejunostomy

BACKGROUND

To evaluate the long-term efficacy of single-balloon enteroscopy endoscopic retrograde cholangiography (SBE-ERC) for the treatment of biliary obstruction and to analyze the factors affecting the recurrence of benign bilioenteric anastomotic stricture after SBE-ERC treatment.

METHODS

The clinical data of patients with biliary diseases treated with SBE-ERC after choledochojejunostomy in our hospital from January 2015 to December 2021 were analyzed retrospectively for the success rates of diagnosis and treatment and the incidence of complications. Patients who were diagnosed with benign bilioenteric anastomotic stricture were followed up. The independent factors affecting recurrence were obtained by univariate and multivariate analyses using the Kaplan‒Meier method and Cox proportional hazard regression model.

RESULTS

A total of 289 SBE-ERCs were performed in 165 patients. The overall success rate was 83.0% (240/289). The incidence of postoperative complications was 5.2% (15/289). The 108 successfully treated patients diagnosed with benign bilioenteric anastomotic stricture were followed up. Twenty-six percent (29/108) of patients had recurrent stricture after SBE-ERC. The biliary patency rates at 1 year, 2 years and 5 years after SBE-ERC were 90.1%, 69.3%, and 53.9%, respectively. Single-factor analysis revealed the absence of intrahepatic biliary gas imaging during endoscopy (χ 2 =5.366, P = 0.021), a diameter of balloon dilatation during the last endoscopic treatment less than 0.8 cm (χ 2 =4.552, P = 0.033), and the presence of a thread in the anastomosis (χ 2 =8.921, P = 0.003) as risk factors for recurrence. A non-indwelling biliary plastic stent (χ 2 =14.868, P < 0.001) and undergoing only one ERCP treatment (χ 2 =13.313, P = 0.001) were risk factors for the recurrence of benign stricture after SBE-ERC resection. Multivariate analysis revealed that the absence of a stent (HR = 0.15, 95% CI 0.06-0.40, P = 0.001), absence of intrahepatic biliary gas imaging during endoscopy (HR = 0.39, 95% CI 0.17-0.91, P = 0.03) and the presence of a thread in the anastomosis (HR = 3.69, 95% CI 1.59-8.57, P = 0.002) were independent risk factors for stricture recurrence.

CONCLUSIONS

Treating biliary disease after choledochojejunostomy with SBE-ERC is safe and effective, with a good immediate technical success rate and an acceptable incidence of complications. SBE-ERC has long-term efficacy in the treatment of benign bilioenteric anastomotic stricture. The absence of intrahepatic biliary gas imaging during endoscopy, non-indwelling biliary stents and the existence of anastomotic threads are independent risk factors for the recurrence of benign bilioenteric anastomotic stricture.

Factors affecting complete stone removal and bile duct stone recurrence in patients with surgically altered anatomy treated by double-balloon endoscopy-assisted endoscopic retrograde cholangiography

OBJECTIVES

This study assessed factors influencing the complete removal and recurrence of bile duct stones in patients with surgically altered anatomy (SAA) undergoing double-balloon endoscopy-assisted endoscopic retrograde cholangiography (DBERC).

METHODS

A retrospective analysis of 289 patients with SAA treated for biliary stones with DBERC at Jichi Medical University Hospital (January 2007 to December 2022) was conducted. Evaluation of factors impacting complete stone removal was performed in 257 patients with successful bile duct cannulation. Logistic and Cox proportional hazards regression models were used to compute the odds ratios (ORs) and hazard ratios (HRs) at 95% confidence intervals (CIs).

RESULTS

Of 257 patients, 139 (54.0%) and 209 (81.3%) achieved initial and complete removal, respectively. Recurrence occurred in 55 (21.4%) patients. Factors associated with initial complete stone removal included cholangitis (P < 0.01, OR 0.48, 95% CI 0.27-0.83), number of stones (P < 0.01, OR 0.31, 95% CI 0.18-0.54), and largest stone diameter (P < 0.01, OR 0.37, 95% CI 0.20-0.67). The size of the largest stone was associated with complete removal (P = 0.01, OR 0.24, 95% CI 0.13-0.76). Recurrence was associated with cholangitis (P = 0.046, HR 0.54, 95% CI 0.29-0.99), congenital biliary dilatation (P = 0.01, HR 2.65, 95% CI 1.21-5.80), and number of stones (P = 0.02, HR 1.96, 95% CI 1.12-3.41).

CONCLUSIONS

Successful complete bile stone removal in patients with SAA depends on the stone diameter and number. Stone recurrence is influenced by the number of stones and history of congenital biliary dilatation.

Safety and Efficacy of Covered Self-Expandable Metallic Stent for Choledochojejunal Anastomotic Stricture: A Multi-Center Retrospective Cohort Study

BACKGROUND

Benign choledochojejunal anastomotic stricture (CJS) is a complication of pancreaticoduodenectomy and choledochojejunostomy. Typically managed with endoscopic balloon dilatation, CJS has a high recurrence rate. Covered metallic stent (CMS) placement is a potential alternative; however, a comprehensive evaluation is lacking.

OBJECTIVES

The aim of this study was to evaluate the treatment outcomes of CMS placement in patients with CJS.

METHODS

We retrospectively analyzed patients who underwent balloon dilation via endoscopic retrograde cholangiopancreatography using a double-balloon endoscope for CJS between October 2010 and October 2023. The study outcomes included technical and clinical success rates, adverse event rates, choledochojejunal anastomotic stricture recurrence rates, and time to recurrence for balloon dilation and CMS treatment for CJS.

RESULTS

There were 43 patients, 55 procedures (40 balloon dilation and 15 CMS placement). The technical and clinical success rates were 100% for both treatments. Recurrence of CJS was observed in 35% (14/40) of the patients in the balloon dilation group. The recurrence rate was significantly higher in the balloon dilation group than in the CMS group (35% vs. 0%, p = 0.006). The time to CJS recurrence was significantly shorter in the balloon dilation group than in the covered metallic stent group (NR vs. NR, p = 0.03).

CONCLUSION

Placement of CMS for treating patients with CJS was demonstrated to be an effective and safe method with a lower recurrence rate than balloon dilation.

Endoscopic approach for biliopancreatic disease after pancreaticoduodenectomy: a 10-year single-center experience

BACKGROUND AND AIM

In surgically altered anatomy (SAA), endoscopic retrograde cholangiopancreatography (ERCP) can be challenging, and it remains debatable the choice of the optimal endoscopic approach within this context. We aim to show our experience and evaluate the technical and clinical success of endoscopic treatment performed in the setting of adverse events (AE) after pancreaticoduodenectomy (PD).

METHODS

This study was conducted on a retrospective cohort of patients presenting biliopancreatic complications after PD from 01/01/2012 to 31/12/2022. All patients underwent ERCP at our Endoscopy Unit. Clinical, instrumental data, and characteristics of endoscopic treatments were collected.

RESULTS

133 patients were included (80 M, mean age = 65 y.o.) with a total of 296 endoscopic procedures (median = 2 procedures/treatment). The indications for ERCP were mainly biliary AE (76 cases, 57.1%). Technical success was obtained in 121 patients of 133 (90.9%). 112 out of 133 (84.2%) obtained clinical success. Nine patients out of 112 (8%) experienced AEs. Clinical success rates were statistically different between patients with biliary or pancreatic disease (93.4% vs 73.6%, p < 0.0001). Septic patients were 38 (28.6%) and showed a worse prognosis than non-septic ones (clinical success: 65.7% vs 91.5%, p = 0.0001). During follow-up, 9 patients (8%), experienced recurrence of the index biliopancreatic disease with a median onset at 20 months (IQR 6-40.1).

CONCLUSION

Our case series demonstrated that the use of a pediatric colonoscope in ERCP procedures for patients with AEs after PD is both safe and effective in treating the condition, even in a long-term follow-up.

Advanced technical tips and recent insights in ERCP using balloon-assisted endoscopy

Pancreatobiliary endoscopic interventions using balloon-assisted endoscopes have been widely acknowledged as the first-line therapy for pancreatobiliary diseases in postoperative patients with reconstructed gastrointestinal anatomy (excluding the Billroth I procedure). However, there are many technical difficulties, and the procedural completion rates vary in a wide range among institutions, indicating the procedural technique is yet to be standardized. This article aims to provide technical tips of procedures and insights into the advanced aspects, including the management of extremely difficult cases and troubleshooting of endoscopic retrograde cholangiopancreatography using balloon endoscopy, along with a review of recent advancements in this field.

Risk factors for recurrent stenosis after balloon dilation for benign hepaticojejunostomy anastomotic stricture

BACKGROUND/AIMS

Hepaticojejunostomy anastomotic stricture (HJAS) is a feared adverse event associated with hepatopancreatobiliary surgery. Although balloon dilation for benign HJAS during endoscopic retrograde cholangiopancreatography with balloon-assisted enteroscopy has been reported to be useful, the treatment strategy remains controversial. Therefore, we evaluated the outcomes and risk factors of recurrent stenosis after balloon dilation alone for benign HJAS.

METHODS

We retrospectively analyzed consecutive patients who underwent balloon-assisted enteroscopy-endoscopic retrograde cholangiopancreatography for benign HJAS at our institution between July 2014 and December 2020.

RESULTS

Forty-six patients were included, 16 of whom had recurrent HJAS after balloon dilation. The patency rates at 1 and 2 years after balloon dilation were 76.8% and 64.2%, respectively. Presence of a residual balloon notch during balloon dilation was an independent predictor of recurrence (hazard ratio, 2.80; 95% confidence interval, 1.01-7.78; p=0.048), whereas HJAS within postoperative 1 year tended to be associated with recurrence (hazard ratio, 2.43; 95% confidence interval, 0.85-6.89; p=0.096). The patency rates in patients without a residual balloon notch were 82.1% and 73.1% after 1 and 2 years, respectively.

CONCLUSION

Balloon dilation alone may be a viable option for patients with benign HJAS without residual balloon notches on fluoroscopy.

Clinical utility of the forward-viewing echoendoscope in patients after pancreatoduodenectomy: A prospective study

Background and Objectives

Endoscopic treatment of obstructive jaundice and pancreatitis due to hepaticojejunostomy (H-J), pancreatojejunostomy (P-J) strictures, and tumor recurrence after pancreatoduodenectomy (PD) is technically challenging. Treatment of P-J strictures results in poor outcomes. Although conventional EUS that has an oblique view is not suitable for such patients, forward-viewing EUS (FV-EUS) may become a useful option. This study aimed to evaluate the feasibility and efficacy of FV-EUS in patients who have undergone PD.

Methods

Patients with PD who were scheduled to undergo diagnosis and treatment using FV-EUS for H-J or P-J lesions were enrolled in this single-center prospective study. After observation of the P-J and H-J using FV-EUS according to a predetermined protocol, treatment using FV-EUS was performed as needed.

Results

A total of 30 patients were enrolled, and FV-EUS was used to observe P-J and H-J in 24 and 28 patients, respectively. The detection rates of P-J and H-J by endoscopy were 50% (12/24) and 96.4% (27/28), respectively, and by EUS were 70.8% (17/24) and 100% (28/28), respectively. Of these, P-J and H-J were found by endoscopy only after EUS observation in 3 and 1 patient, respectively. The success rates of endoscopic treatment using FV-EUS were 66.7% (2/3), 95.2% (20/21), and 25% (1/4) for benign P-J strictures, benign H-J strictures, and tumor recurrence, respectively.

Conclusions

Endoscopic treatment using FV-EUS is feasible and effective for patients after PD. Moreover, FV-EUS increases the P-J lesion detection rate by adding EUS observation.

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.

Hepaticojejunostomy with gastric access loop versus conventional hepaticojejunostomy: a randomized trial

Roux-en-Y hepaticojejunostomy (RYHJ) with the provision of "gastric access loop" was developed to shorten the distance traveled by the endoscope to reach hepaticojejunostomy (HJ) anastomotic site. The aim of our study was to assess modified RYHJ with gastric access loop (RYHJ-GA) and compare it with conventional RYHJ (RYHJ-C) regarding short- and long-term outcomes and, moreover, to evaluate the feasibility and results of future endoscopic access of the modified bilio-enteric anastomosis. Patients eligible for RYHJ between September 2017 and December 2019 were allocated randomly to receive either RYHJ-C or RYHJ-GA. Fifty-two patients were randomly assigned to RYHJ-C (n = 26) or RYHJ-GA (n = 26). Three cases in RYHJ-C and 4 cases in RYHJ- GA developed HJ anastomotic stricture (HJAS) (P=0.68). 3 cases of RYHJ-GA had successful endoscopic dilation and balloon sweeping of biliary mud (one case) or stones (2 cases). Revisional surgery was needed in 2 cases of RYHJ-C and 1 case in RYHJ-GA (P=0.68). Modified RYHJ with gastric access loop is comparable to the classic hepaticojejunostomy regarding complications. However, gastric access enables easy endoscopic access for the management of future HJAS. This modification should be considered in patients with a high risk of HJAS during long-term follow-up.The trial registration number (TRN) and date of registration:ClinicalTrials.gov (NCT03252379), August 17, 2017.

Clinical outcome of endoscopic treatment of symptomatic Hepaticojejunal anastomotic strictures after pancreatoduodenectomy

BACKGROUND

Hepaticojejunostomy anastomotic stricture (HJAS) is an adverse event after pancreatoduodenectomy (PD) which can result in jaundice and/or cholangitis. With endoscopy, HJAS can be managed. However, few studies report the specific success and adverse event rates of endoscopic therapy after PD.

METHODS

Patients with symptomatic HJAS, who underwent an endoscopic retrograde cholangiopancreatography at the Erasmus MC between 2004-2020, were retrospectively included. Primary outcomes were short-term clinical success defined as no need for re-intervention <3 months and long-term <12 months. Secondary outcome measures were cannulation success and adverse events. Recurrence was defined as symptoms with radiological/endoscopic confirmation.

RESULTS

A total of 62 patients were included. The hepaticojejunostomy was reached in 49/62 (79%) of the patients, subsequently cannulated in 42/49 (86%) and in 35/42 patients (83%) an intervention was performed. Recurrence of symptomatic HJAS after technically successful intervention occurred in 20 (57%) patients after median time to recurrence of 7.5 months [95%CI, 7.2-NA]. Adverse events were reported in 4% of the procedures (8% of patients), mostly concerning cholangitis.

DISCUSSION

Endoscopic treatment for symptomatic HJAS after PD has a moderate technical success rate and a high recurrence rate. Future studies should optimize endoscopic treatment protocols and compare percutaneous versus endoscopic treatment.

Long- and short-term outcomes of balloon dilation for benign choledochojejunal anastomotic stricture using balloon endoscopy-assisted ERCP: a multi-center retrospective cohort study

BACKGROUND

Benign choledochojejunal anastomotic stricture (CJS) is a common complication of pancreaticoduodenectomy and choledochojejunostomy. CJS is generally treated with balloon dilation, using balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP); however, its long- and short-term outcomes have not been fully evaluated. Therefore, we evaluated the treatment outcomes of balloon dilation with BE-ERCP for CJS.

METHODS

We retrospectively analyzed 40 patients who had undergone balloon dilation with BE-ERCP for CJS between January 2009 and December 2022. The primary outcomes were technical and clinical success, and adverse event rates of balloon dilation using BE-ERCP for CJS. The secondary outcomes were long-term treatment outcomes for CJS recurrence, and evaluation of risk factors for recurrence.

RESULT

Technical and clinical success rates were 93% (37/40) and 100% (37/37), respectively. CJS recurrence occurred in 32% (20/37). No procedure-related adverse events were observed. The significant risk factors of CJS after balloon dilation were its early occurrence after surgery (unit hazard ratio [HR] for month, 0.87; 95% confidence interval [CI], 0.76-0.99; p-value = 0.04) and residual waist during balloon dilation (HR, 5.46; 95% CI, 1.18-25.1; p-value = 0.03). Receiver operating characteristic curve analysis of time from surgery to balloon dilation revealed an area under the curve of 0.80 (95% CI, 0.65-0.94) and the cut-off value was 13.2 months.

CONCLUSION

Treatment of CJS with balloon dilation was effective, although CJS recurrence occurred in one-third of the patients. The risk factors for recurrence were early occurrence of CJS after surgery and remaining waist circumference during balloon dilation.

[Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]

Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.

Outcomes of patients with hepaticojejunostomy anastomotic strictures undergoing endoscopic and percutaneous treatment

Background and study aims  The increase in hepaticojejunostomies has led to an increase in benign strictures of the anastomosis. Double balloon enteroscopy-assisted ERCP (DBE-ERCP) and percutaneous transhepatic biliary drainage (PTBD) are treatment options; however, there is lack of long-term outcomes, with no consensus on management. We performed a retrospective study assessing the outcomes of patients referred for endoscopic management of hepaticojejunostomy anastomotic strictures (HJAS). Patients and methods  All consecutive patients at a tertiary institution underwent endoscopic intervention for suspected HJAS between 2009 and 2021 were enrolled. Results  Eighty-two subjects underwent DBE-ERCP for suspected HJAS. The technical success rate was 77 % (63/82). HJAS was confirmed in 41 patients. The clinical success rate for DBE-ERCP ± PTBD was 71 % (29/41). DBE-ERCP alone achieved clinical success in 49 % of patients (20/41). PTBD was required in 49 % (20/41). Dual therapy was required in 22 % (9/41). Those with liver transplant had less technical success compared to other surgeries (72.1 % vs 82.1 % P  = 0.29), less clinical success with DBE-ERCP alone (40 % vs 62.5 % P  = 0.16) and required more PTBD (56 % vs 37.5 % P  = 0.25). All those with ischemic biliopathy (n = 9) required PTBD for clinical success, required more DBE-ERCP (4.4 vs 2.0, P = 0.004), more PTBD (4.7 vs 0.3, P  < 0.0001), longer treatment duration (181.6 vs 99.5 days P  = 0.12), and had higher rates of recurrence (55.6 % vs 30.3 % P  = 0.18) compared to those with HJAS alone. Liver transplant was the leading cause of ischemic biliopathy (89 %). The overall adverse event rate was 7 %. Conclusions  DBE-ERCP is an effective diagnostic and therapeutic tool in those with altered gastrointestinal anatomy and is associated with low complication rates.

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

BACKGROUND

In recent years, the number of patients with hepaticojejunostomy anastomotic strictures has increased. Balloon dilation and placement of multiple plastic stents have proven effective for hepaticojejunostomy anastomotic strictures. However, for refractory strictures, there is often a need for repeated endoscopic procedures within a short period. This study aimed to assess the efficacy and safety of the new saddle-cross technique, which uses two fully covered self-expandable metallic stents.

METHODS

This was a retrospective analysis of 20 patients with benign hepaticojejunostomy anastomotic strictures who underwent placement of two fully covered self-expandable metallic stents at the National Cancer Center, Japan, from November 2017 to June 2021.

RESULTS

The technical and clinical success rates were 100% (20/20). The median time of the procedure was 61 (range 25-122) min. The scheduled stent removal rate was 70% (14/20). Spontaneous dislodgement of the stent was observed on computed tomography in five patients (25.0%). The non-restenosis rate 12 months after the saddle-cross technique was 88.2% (15/17). Procedure-related early adverse events included mild ascending cholangitis in three patients (15.0%) and sepsis in one patient (5.0%). Procedure-related late adverse events included mild ascending cholangitis in three patients (15.0%) and bile duct hyperplasia in one patient (5.0%).

CONCLUSIONS

The saddle-cross technique performed using two fully covered self-expandable metallic stents resulted in promising long-term stricture resolution with a high technical success rate. Based on these findings, the saddle-cross method can be considered an option for the standard procedure for benign hepaticojejunostomy anastomotic strictures.

Endoskopisches Management von Gallengangskomplikationen nach Leberchirurgie

Biliäre Komplikationen stellen häufige Komplikationen nach Leberchirurgie dar und tragen wesentlich zur postoperativen Morbidität und Mortalität bei. Den größten Anteil dieser machen Gallengangsleckagen und -strikturen aus, wobei die Leckagen nach Cholezystektomie und Leberresektion dominieren und die Strikturen ein wesentliches Problem nach Lebertransplantationen darstellen. Patienten nach orthotoper Lebertransplantation stellen besonders vulnerable Patienten dar, deren biliäre Komplikationen von denen nach Cholezystektomie und Leberresektion differieren und niederschwellig sowie mit größter Vorsicht behandelt werden müssen. Mit der endoskopischen retrograden Cholangiografie steht ein exzellentes Verfahren zur Behandlung dieser Komplikationen zur Verfügung. Die therapeutischen Möglichkeiten beinhalten die endoskopische Sphinkterotomie, die Anlage von Prothesen und Dilatationen. Mittels dieser Verfahren können Erfolgsraten in bis zu 90% der Fälle erreicht werden. Bei Hepatikojejunostomien bestehen alternative Interventionsmöglichkeiten wie die ballon- oder motorunterstützte antegrade Enteroskopie, die perkutan-transhepatische Cholangiodrainage oder mit zunehmendem Einsatz die endosonografisch gestützten Verfahren.

Percutaneous Biliary Interventions: Clinical Indications, Comparative Effectiveness, Technical Considerations, Complications, and Outcomes

Percutaneous biliary interventions (PBIs) are commonly performed by interventional radiologists for a variety of clinical indications including biliary infections, strictures, leaks, and postoperative complications. PBIs have high technical and clinical success rates and are relatively safe when compared with more invasive surgical techniques. Percutaneous transhepatic cholangiography and percutaneous biliary drainage play an essential role in the management of common posthepatobiliary complications including biliary strictures and leaks. Percutaneous biliary endoscopy can be used for direct visualization of the biliary tree and a variety of interventions including tissue biopsy, lithotripsy, stone removal, as well as stent placement and removal.

Robotic Revision of Hepaticojejunostomy for Benign Biliary Stricture

Surgical revision of biliary enteric anastomoses (BEA) can be a challenging undertaking and a robotic platform may provide advantages that address many of the technical obstacles. We present our technical approach and outcomes for patients undergoing robotic revision of BEA for benign strictures. A retrospective review was performed for robot-assisted benign BEA revision at our institution. Operative details, perioperative metrics, and outcomes are reported. Four patients underwent anastomotic revision following previously failed non-operative management. There were no intraoperative complications, mean length of stay was 4-days, and all patients experienced resolution of presenting clinical signs and symptoms. No patients required reoperation and there was no mortality. Postoperative outcomes were consistent with findings reported for other interventional modalities. Based on our experience we conclude robotic intervention in this context is safe and improves the technical feasibility of this complex procedure.

Biliary stones or ulcers at the choledochojejunal anastomotic site involving the jejunal mucosa at stent removal may be recurrent factors in patients with benign choledochojejunal anastomotic stenosis undergoing endoscopic biliary stenting using fully-covered self-expandable metal stents

BACKGROUND

Temporary fully-covered self-expandable metal stent (FCSEMS) placement is performed for benign choledochojejunal anastomotic stenosis (bCJS). However, recurrence may develop after stricture resolution. We investigated endoscopic biliary stenting using FCSEMS for bCJS.

METHODS

Sixteen bCJS patients with FCSEMS placement were retrospectively analyzed. FCSEMS was removed endoscopically after 2 months. Technical success, stricture resolution, recurrence, and adverse events were evaluated.

RESULTS

The technical success rate for FCSEMS placement was 94% (15/16). Biliary stones were detected and extracted in 4 patients. FCSEMS removal was successfully performed on 14 patients, excluding 1 with stent migration. At FCSEMS removal, stricture resolution was noted in 14 patients; however, 4 had anastomotic ulcers. The median follow-up was 319 days. Three patients with a history of repeated plastic stent placement had no recurrence. Four out of 15 patients (27%) had recurrence, and three had no recurrence after additional interventions. Biliary stones before first FCSEMS placement (p=0.003) or anastomotic ulcers at FCSEMS removal (p=0.018) were associated with recurrence.

CONCLUSIONS

Although FCSEMS placement was useful for stricture resolution, recurrence was detected in patients with biliary stones before first FCSEMS placement or anastomotic ulcers at FCSEMS removal. Anastomotic ulcers are a risk factor for recurrence and only detected by endoscopy.

Efficacy of double-balloon enteroscopy-assisted endoscopic balloon dilatation combined with stent deployment for hepaticojejunostomy anastomotic stricture

BACKGROUND

Hepaticojejunostomy anastomotic stricture (HJAS) is a significant complication of biliary reconstruction surgery. Endoscopic management of HJAS using double-balloon enteroscopy has expanded; however, retrospective reports in this setting are limited. This study aimed to evaluate the efficacy of endoscopic balloon dilatation combined with stent deployment for HJAS.

METHODS

This was a single-arm prospective clinical trial involving 40 patients with treatment-naïve HJAS enrolled between March 2016 and August 2019 at four endoscopy units in Japan. For HJAS, plastic stents combined with balloon dilatation were placed for 6 months after initial stenting. The primary outcome was HJ anastomosis patency 12 months after stent removal.

RESULTS

The technical success rate was 97.5% (39/40). The failed case required percutaneous transhepatic biliary drainage using the rendezvous technique. All cases achieved successful endoscopic treatment. During the treatment period, four of 40 patients (10%) ended the study protocol due to unrelated causes and were excluded from the primary analysis. Among the 36 patients, clinical success was achieved in 34 (94.4%) patients. The remaining two patients achieved HJAS resolution after an additional 3 months. All 36 patients achieved HJAS resolution. Adverse events were observed in two patients (5.0%) who developed moderate cholangitis. During a median follow-up of 21.3 months, HJAS recurrence was observed in 8.3% (3/36) with a median time to recurrence of 4.3 months and HJ anastomosis patency at 12 months was 94.4%.

CONCLUSIONS

Endoscopic balloon dilatation combined with plastic stent deployment for 6 months was a safe and effective strategy for HJAS. (Clinical Trial Registry no. UMIN000020613).

The Efficacy and Safety of Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiography in Pediatric Patients with Surgically Altered Gastrointestinal Anatomy

Balloon enteroscopy-assisted endoscopic retrograde cholangiography (BEA-ERC) is useful and feasible in adults with pancreatobiliary diseases, but its efficacy and safety have not been established in pediatric patients. We compared the success rate and safety of BEA-ERC between adults and pediatric patients. This single-center retrospective study reviewed 348 patients (pediatric: 57, adult: 291) with surgically altered gastrointestinal anatomies who underwent BEA-ERC for biliary disorders from January 2007 to December 2019. The success rate of reaching the anastomosis or duodenal papilla was significantly lower in pediatric patients than in adult patients (66.7% vs. 88.0%, p < 0.01). The clinical success rate was also significantly lower in pediatric patients (64.9% vs. 80.4%, p = 0.014). The rate of adverse events was significantly higher in pediatric patients than in adults (14.2% vs. 7.7%, p = 0.037). However, if the anastomotic sites were reached in pediatric patients, the treatment was highly successful (97.3%). The time of reaching target site was significantly longer in pediatric patients than in adult patients. This study shows that BEA-ERC in pediatric patients is more difficult than that in adult patients. However, in patients where the balloon enteroscope was advanced to the anastomosis, clinical outcomes comparable to those in adults can be achieved.

Double-balloon endoscopic retrograde cholangiography can make a reliable diagnosis and good prognosis for postoperative complications of congenital biliary dilatation

Bile duct and anastomotic strictures and intrahepatic stones are common postoperative complications of congenital biliary dilatation (CBD). We performed double-balloon endoscopic retrograde cholangiography (DBERC) for diagnostic and therapeutic purposes after radical surgery. We focused on the effectiveness of DBERC for the treatment of postoperative complications of CBD patients. Bile duct and anastomotic strictures and intrahepatic stones are common postoperative complications of congenital biliary dilatation (CBD). We performed double-balloon endoscopic retrograde cholangiography (DBERC) for diagnostic and therapeutic purposes after radical surgery. We focused on the effectiveness of DBERC for the treatment of postoperative complications of CBD patients. This retrospective study included 28 patients who underwent DBERC (44 procedures) after radical surgery for CBD between January 2011 and December 2019. Strictures were diagnosed as “bile duct strictures” if endoscopy confirmed the presence of bile duct mucosa between the stenotic and anastomotic regions, and as “anastomotic strictures” if the mucosa was absent. The median patient age was 4 (range 0–67) years at the time of primary surgery for CBD and 27.5 (range 8–76) years at the time of DBERC. All anastomotic strictures could be treated with only by 1–2 courses of balloon dilatation of DBERC, while many bile duct strictures (41.2%) needed ≥ 3 treatments, especially those who underwent operative bile duct plasty as the first treatment (83.3%). Although the study was limited by the short follow-up period after DBERC treatment, DBERC is recommended as the first-line treatment for hepatolithiasis associated with biliary and anastomotic strictures in CBD patients, and it can be safely performed multiple times.

Liver resections in patients with prior bilioenteric anastomosis are predisposed to develop organ/space surgical site infections and biliary leakage: results from a propensity score matching analysis

PURPOSE

The aims of this study were to compare the perioperative outcomes after hepatectomy with prior bilioenteric anastomosis to those without prior anastomosis, and to elucidate the mechanisms and preventative measures of its characteristic complications.

METHODS

The demographic data and perioperative outcomes of 525 hepatectomies performed between January 2007 and December 2018, including 40 hepatectomies with prior bilioenteric anastomosis, were retrospectively analyzed.

RESULTS

A propensity score matching analysis demonstrated that hepatectomies with prior bilioenteric anastomosis were associated with a higher frequency of major complications (p = 0.015), surgical site infection (p = 0.005), organ/space surgical site infection (p = 0.003), and bile leakage (p = 0.007) compared to those without. A multivariate analysis also elucidated that prior bilioenteric anastomosis was one of the independent risk factors of organ/space surgical site infection. In the patients with prior bilioenteric anastomosis, bile leakage was associated with organ/space surgical site infection at a significantly higher rate than those without prior bilioenteric anastomosis (p < 0.001).

CONCLUSIONS

Prior bilioenteric anastomosis is a strong risk factor for organ/space surgical site infections, which might be induced by bile leakage. To prevent infectious complications after hepatectomy with prior bilioenteric anastomosis, meticulous liver transection to reduce bile leakage rate is thus considered to be mandatory.

Technical feasibility and safety of transluminal antegrade dilation for hepaticojejunostomy stricture using a novel fine-gauge electrocautery dilator (with video)

Background and study aims  A novel fine-gauge electrocautery dilator (ED) has recently become available in Japan. The current study evaluated the safety and feasibility of transluminal antegrade dilation for hepaticojejunal stricture (HJS) using this novel ED. Patients and methods  Patients who with complicated HJS were retrospectively enrolled. The primary and secondary endpoints of this study were rates of technical success defined as functional antegrade HJS dilation using the novel ED and types of adverse events, respectively. A total of 22 patients were enrolled. Among them, six were treated using an enteroscopic approach due to the absence of bile duct dilation or patient refusal to undergo EUS-HGS. Therefore, 16 patients underwent EUS-HGS. Results  The procedure was successful in 15 of 16 patients (93.8 %). The contrast medium flowed from the intrahepatic bile duct to the intestine of 14 of 15 patients (93.3 %). The resolution rate of HJS was 13 of 14 (92.9 %) at 6 months. Conclusion  Our technique might offer a new option with which to treat HJS, although a prospective study with long-term follow-up is needed.

Biliary Stricture: The Achilles Heel of Pediatric Living Donor Liver Transplantation

Since a 1989 report demonstrating successful living donor liver transplantation (LDLT), living donors have been increasingly used to overcome the disparity between organ supply and demand, especially in the cases of pediatric patients. Although short-term graft outcomes after LDLT have improved significantly because of progress in surgical techniques and immunosuppression, biliary stricture (BS) remains the Achilles heel of pediatric LDLT and is the major cause of significant long-term morbidity. BS results in poor quality of life or even in graft loss after LDLT, with a reported incidence of BS after pediatric LDLT of 10% to 35%. The suggested risk factors for BS after LDLT are hepatic arterial thrombosis, bile duct ischemia, acute cellular rejection, older donor age, and ABO incompatibility. Duct-to-duct biliary reconstruction, which enables an endoscopic approach to be attempted after BS, is the preferred technique for LDLT. Endoscopic approaches are less invasive and more convenient for recipients than surgical and percutaneous interventions. However, the major cause of end-stage liver disease in pediatric recipients is biliary atresia, and hepaticojejunostomy is needed to reconstruct the bile duct because of the lack of recipient bile duct. Endoscopic approaches for BS are usually less favorable in patients with hepaticojejunostomy than in those with duct-to-duct biliary reconstruction. Treatment options for BS after hepaticojejunostomy at many centers thus involve interventional radiology or surgical reintervention. Although endoscopic approaches remain controversial in pediatric recipients, several reports have shown them to be safe and less invasive.

Double-balloon endoscopic retrograde cholangiopancreatography for patients who underwent liver operation: A retrospective study

BACKGROUND

Double-balloon endoscopic retrograde cholangiography (DB-ERC) is widely performed for biliary diseases after reconstruction in gastrointestinal surgery, but there are few reports on DB-ERC after hepatectomy or living donor liver transplantation (LDLT).

AIM

To examine the success rates and safety of DB-ERC after hepatectomy or LDLT.

METHODS

The study was performed retrospectively in 26 patients (45 procedures) who underwent hepatectomy or LDLT (liver operation: LO group) and 40 control patients (59 procedures) who underwent pancreatoduodenectomy (control group). The technical success (endoscope reaching the choledochojejunostomy site), diagnostic success (performance of cholangiography), therapeutic success (completed interventions) and overall success rates, insertion and procedure (completion of DB-ERC) time, and adverse events were compared between these groups.

RESULTS

There were no significant differences between LO and control groups in the technical [93.3% (42/45) vs 96.6% (57/59), P = 0.439], diagnostic [83.3% (35/42) vs 83.6% (46/55), P = 0.968], therapeutic [97.0% (32/33) vs 97.7% (43/44), P = 0.836], and overall [75.6% (34/45) vs 79.7% (47/59), P = 0.617] success rates. The median insertion time (22 vs 14 min, P < 0.001) and procedure time (43.5 vs 30 min, P = 0.033) were significantly longer in the LO group. The incidence of adverse events showed no significant difference [11.1% (5/45) vs 6.8% (4/59), P = 0.670].

CONCLUSION

DB-ERC after liver operation is safe and useful but longer time is required, so should be performed with particular care.

Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.

Severe Biliary Stricture Dilation Using the Soehendra Stent Retriever with a Short-Type Balloon Enteroscope in Patients with Surgically Altered Anatomies

BACKGROUND

Balloon enteroscopy (BE) can be used for endoscopic retrograde cholangiography (ERC) to treat biliary strictures in patients with surgically altered anatomies. However, biliary strictures, including bilioenteric anastomotic strictures, are often very severe and dilation catheters cannot pass through them. The Soehendra stent retriever (SSR) is like a screw drill and can be useful for dilating severe strictures, but the utility of SSR during BE-assisted ERC (BE-ERC) is unclear. This study aimed to examine the efficacy and safety of a dilation technique using the SSR during BE-ERC.

METHODS

Between 2014 and 2018, 28 patients with surgically altered gastrointestinal anatomies and severe biliary strictures underwent BE-ERC, and the SSR was used for the dilation procedures. We evaluated the technical success, therapeutic success, and adverse event rates associated with SSR dilation.

RESULTS

The technical success rate was 93% (26/28). The procedures undertaken on two patients with non-anastomotic strictures failed technically because the SSR was not long enough to reach the strictures. The therapeutic success rate was 96% (25/26) for the patients whose procedures were technically successful. The adverse event rate was 7% (2/28), and the adverse events were mild and improved with conservative management. No bleeding or duct perforations occurred.

CONCLUSIONS

Although the indications for using the SSR in patients with non-anastomotic strictures should be considered based on the distance between the tip of the scope and the stricture's location, SSR dilation may be a useful option during BE-ERC if a biliary stricture is very severe.

Technical feasibility of EUS-guided antegrade dilation for hepaticojejunostomy anastomotic stricture using novel endoscopic device (with videos)

Background

A novel endoscopic dilation device (EZ Dilator; Zeon Medical Co, Tokyo, Japan) is now available in Japan that might affect dilation for biliary strictures under endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) guidance because it has good push ability. We evaluated the technical feasibility of this device under EUS guidance in a case series of patients with hepaticojejunostomy anastomotic stricture (HJAS) that led to further complications.

Method

We enrolled 14 patients with HJAS leading to obstructive jaundice or repeated cholangitis in this study. Technical success was defined as insertion of the EZ Dilator into the intestine across the stricture site without the need for other dilation devices. Deployed plastic stents were removed after three months to evaluate anastomosis sites.

Results

The median procedural duration was 25 minutes. Rates of technical and clinical success were 100% and 78.5%, respectively. One patient developed an adverse event of abdominal pain. Contrast medium flowed across the anastomosis site in 11 patients after stent removal, indicating a clinical success rate of 78.5% (11 of 14). Plastic stents were deployed again in the remaining three patients.

Conclusion

Although a prospective evaluation with long-term follow up is needed, the EZ Dilator shows clinical promise for treating benign biliary strictures under ERCP and EUS guidance.

Long-term outcomes of EUS-guided transluminal stent deployment for benign biliary disease: Multicenter clinical experience (with videos)

Background and Objectives:

Biliary drainage (BD) under EUS guidance is usually indicated for malignant biliary obstruction. Recently, EUS-guided transluminal treatment has been applied to benign biliary disease (BBD). This multicenter retrospective study evaluated the clinical impact of EUS-guided transluminal stent deployment for BBD with long-term follow-up.

Patients and Methods:

This retrospective study investigated patients treated between September 2015 and October 2016 at participating hospitals in the therapeutic endoscopic group. The inclusion criteria comprised complications with BBD obstructive jaundice or cholangitis and failed endoscopic retrograde cholangiopancreatography or inaccessible ampulla of Vater.

Results:

Twenty-six patients underwent EUS-guided transluminal stent deployment. Indications for EUS-guided transluminal stent deployment comprised anastomotic biliary stricture (n = 17), bile duct stones (n = 5), inflammatory biliary stricture (n = 3), and acute pancreatitis prevention (n = 1). Thirteen of these 26 patients underwent scheduled reintervention, with technical success achieved in all 13 patients. None of the deployed stents became dysfunctional. Among the 13 patients who underwent reintervention on demand, stents had become dysfunctional in six patients (stent patency: 48, 90, 172, 288, 289, and 608 days). Reintervention was successfully performed in all patients. During follow-up (median, 749 days), severe adverse events were not seen in any patients.

Conclusion:

We concluded that EUS-guided transluminal stent deployment for BBD is feasible and safe. Because metal stent dysfunction was more frequent when deployed on demand, such stents should be exchanged for plastic stents in a scheduled manner if a metal stent is used.

Rendezvous Technique Using Double Balloon Endoscope for Removal of Multiple Intrahepatic Bile Duct Stones in Hepaticojejunostomy After Living Donor Liver Transplant: A Case Report

Cholangitis is a major complication following transplantation. We report a living donor liver transplant (LDLT) patient with cholangitis due to multiple stones in the intrahepatic bile duct during hepaticojejunostomy anastomosis, who was successfully treated with the rendezvous technique using double balloon endoscope. A 64-year-old woman underwent LDLT with right lobe graft and hepaticojejunostomy for Wilson disease. There was bile leakage with biliary peritonitis, which was treated conservatively after transplant. Two years after surgery, she developed reiterated cholangitis due to stenosis of hepaticojejunostomy anastomosis and multiple stones in the intrahepatic bile ducts. Percutaneous transhepatic biliary drainage was performed. The size of the drainage tube was increased, and the anastomotic area was dilated in a stepwise manner using a balloon catheter. The stones were crushed and lithotomy was performed using electronic hydraulic lithotripsy through cholangioscopy. Finally, lithotomy was performed for the remaining stones through endoscopic retrograde cholangiography with the rendezvous technique using the double balloon endoscope. Rendezvous approach with percutaneous transhepatic biliary drainage and double balloon endoscopic retrograde cholangiography was an effective treatment for the multiple intrahepatic stones in hepaticojejunostomy following LDLT with right lobe graft.