Background Management of biliary adverse events (BAEs) after biliodigestive anastomosis is challenging. We propose a new endoscopic approach to improve BAEs in this clinical setting. Methods Patients who had BAEs after a hepaticojejunostomy with Roux-en-Y loop or a Whipple procedure underwent creation of an entero-enteral endoscopic bypass (EEEB) between the duodenal/gastric wall and the biliary jejunal loop under endoscopic ultrasound (EUS) and fluoroscopic guidance using specifically designed fully covered self-expandable metal stents. Results 32 consecutive patients underwent EEEB, which was successful in all but one patient. One procedural and five long-term mild adverse events occurred. Endoscopic retrograde cholangiography (ERC) through the EEEB successfully treated all types of BAEs in these patients. Disease recurred in two patients who were successfully re-treated through the EEEB. Conclusions Our retrospective study showed that in patients with BAEs after biliodigestive anastomosis, EEEB is safe, feasible, and allows a successful long-term treatment of different BAEs in a tertiary referral center with high-level experience in both endoscopic retrograde cholangiopancreatography and EUS.

Introduction: The usefulness of endoscopic vacuum therapy (EVT) in the setting of postoperative gastrointestinal leaks is widely described. On this basis, we would like to focus a specific application of EVT: the dehiscence of the duodenal stump after upper gastrointestinal surgery. Standard EVT is not applicable in these cases because of technical limitations (length of overtube and devices). However, vacuum stimulates the healing of leaks and fistulas through granulation tissue’s formation and would be effective also in this setting. Materials and Methods: Between October 2019 and January 2020, 7 consecutive patients (4 M, 3 F, 62±9 y old) affected by duodenal stump’s dehiscence were endoscopically treated by the placement of a large-bore (14 to 18 Ch) suction tube across the wall’s defect into the peritoneal cavity. Continuous aspiration at −80/−100 mm Hg was applied. Clinical success was established both by fluoroscopic check injecting contrast medium from the tube to verify the fistula’s closure and by abdominal computed tomography scan to exclude residual fluid collections. Results: Technical and clinical success were achieved in all the patients. The suction tube was maintained in site for 12±5 days in continuous aspiration. The drainage’s output became null in 2±1 days without any intra-abdominal residual fluid collection. The principle of this technique is to let the duodenal walls’ stump to collapse on the intraluminal part of the tube (with subsequent mucosal intussusception into the holes of the tube itself) creating a sort of vacuum-packed barrier to interrupt the outflow of enteric materials into the fistula’s path. It guarantees the fistula’s closure by the gradual formation of granulation tissue. Conclusions: The present technique offers a safe and viable endoscopic alternative to treat duodenal stump’s leaks after upper gastrointestinal surgery.

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Video 1 Intrabiliary thulium laser lithotripsy conducted through a cholangioscopic guide to complete a difficult biliary lithiasis. E-Videos E112Mutignani Massimiliano et al. Thulium laser to manage a difficult biliary lithiasis: a first case report … Endoscopy 2020; 52: E112-E113