Endoscopy after radiology: two-step combined therapy for biliary stricture after Roux-en-Y hepaticojejunostomy.
Benign postoperative anastomotic strictures after hepaticojejunostomy are difficult to manage. Before interventional techniques were developed, surgical intervention was the only option for treatment. A 28-year-old man underwent Whipple procedure with Roux-en-Y hepaticojejunostomy for abdominal trauma. Two years later, a late anastomotic biliary stricture was diagnosed. A percutaneous cholangiography showed a severe stricture in the hepaticojejunostomy. Because of the severity and length of the stricture, and the failure of repeated percutaneous balloon-dilations, we percutaneously placed a self-expandable metal stent, a nitinol polytetrafluoroethylene fully covered flared-type stent, 3 cm in length, with 10 mm of diameter. The patient was soon discharged home in good general condition that remained stable in the 6 months of follow up. To remove the biliary stent, we carried out single-balloon enteroscopy. The stent was captured with a standard polypectomy snare. To avoid injury to the mucosa, the stent was removed through the overtube, which remained in situ. Cholangiogram showed a normal biliary tree, with resolution of the anastomotic stenosis. The patient remained stable throughout the 8 months of follow up, and required no further biliary procedures. In cases of failure of standard procedures, this new two-step, combined percutaneous and endoscopic approach can be useful and feasible, avoiding surgery-related morbidity and mortality. However, the fact that these procedures should be carried out only by highly experienced endoscopists and interventional radiologists familiar with these specialized procedures cannot be overstressed.
Department of Endoscopy, Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy. gcurcio@ismett.edu
Gabriele
G
Curcio
Mario
M
Traina
Roberto
R
Miraglia
Ilaria
I
Tarantino
Luca
L
Barresi
Antonino
A
Granata
Angelo
A
Luca
Bruno
B
Gridelli
D000007:Abdominal Injuries / Q000601:surgery; D000328:Adult; D000714:Anastomosis, Surgical; D001652:Bile Ducts / Q000473:pathology*; D002404:Catheterization; D002758:Cholangiography; D003251:Constriction, Pathologic; D020878:Device Removal; D016145:Endoscopy, Digestive System / Q000379:methods*; D006801:Humans; D007582:Jejunostomy; D008297:Male; D015642:Radiology, Interventional; D017211:Treatment Failure