Stenosis of Hepaticojejunal Anastomosis with Intrahepatic Lithiasis: Treatment with Single-Balloon Enteroscopy-Assisted ERCP

摘要

A 53-year-old male patient with a history of Roux-en-Y hepaticojejunostomy due to an iatrogenic lesion of thebiliary tract during cholecystectomy in 2013 presentedwith recurrent episodes of acute cholangitis. Magneticresonance cholangiopancreatography showed dilation ofthe intrahepatic biliary ducts associated with intrahepaticlithiasis. Due to a high index of suspicion of hepaticojejunalanastomosis stenosis not evident in the magnetic resonancecholangiopancreatography, the patient was referredto our department for enteroscopy-assisted endoscopicretrograde cholangiopancreatography (ERCP).The procedure was performed with a single-balloon enteroscope(SIF-Q180, Olympus Medical Systems?, To-kyo, Japan) with a transparent cap attached at its tip. Afteridentification of the Roux-en-Y anastomosis, the afferentlimb was intubated, followed by progression to the hepaticojejunalanastomosis. A severe stricture of the anastomosiswas identified (Fig. 1). A 0.035-inch guidewire(METII-35-600E, Tracer Metro? DirectTM Wire Guide,Cook?, Bloomington, IN, USA) was passed through thestricture followed by a sphincterotome (CCPT-25ME,Classic Cotton? CannulaTome?, Cook?). Upon contrastinjection, dilation of the intrahepatic ducts was evident.Dilation with a 6- to 8-mm through-the-scope balloon(34106PRO, Endo-Flex?, Düsseldorf, Germany) wasthen performed (Fig. 2, 3) with immediate spontaneousdrainage of multiple small calculi. The intrahepatic bileducts were explored with a balloon catheter, but no morecalculi were identified. The patient was discharged on thesecond day after the procedure and did not present additionalepisodes of acute cholangitis after a 6-month follow-up.