Endoscopic Ultrasound-Guided Rendezvous for Biliary Obstruction in Patient With Prior Whipple Surgery

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy remains a challenging procedure even for the more experienced endoscopists. We present a unique case of an ERCP performed in a patient with prior Whipple surgery, where biliary access was obtained via an endoscopic ultrasound (EUS)-guided rendezvous technique, and cannulation was ultimately done using a modified therapeutic endoscope with successful biliary drainage.

The Use of Oblique-viewing Endoscopic Ultrasound for Accessing the Afferent Limb for Endoscopic Ultrasound-guided Biliary Drainage in Patients with Severe Stenotic Hepaticojejunal Anastomosis: One Case and Literature Review

“…Endoscopic retrograde cholangiopancreatography (ERCP) as a treatment for hepaticojejunal anastomotic strictures in patients with surgically altered anastomosis (SAA) is challenging, even for experienced endoscopists 1 . The challenges include accessing the biliary limb, cannulation of the ampulla or hepaticojejunostomy, often in suboptimal orientations, and the need for alternative endoscopes other than the conventional duodenoscope 2 . The incidence of anastomotic stricture after hepaticojejunostomy reportedly ranges between 4% and 11.9% 3 .…”

“…This detailed question directly relates to the evaluation of whether the use of OV-EUS for bile drainage in patients with SAA is a radical and risky procedure or a constructive procedure that can be recommended. (2). What kind of stent should be chosen, metal stents, plastic stents, or metal stents combined with plastic stents?…”

“…Even so, once the biliary limb is intubated and the hepaticojejunal anastomosis is identified, biliary cannulation can still be challenging due to the orientation of the anastomosis and the lack of an elevator mechanism if using an endoscope other than the traditional duodenoscope. In addition, challenges can include the inability to use common ERCP instruments, which may not be compatible with balloon enteroscopes 2 . Percutaneous transhepatic biliary drainage (PTBD) with balloon dilation and internal-external drainage placement represents the standard therapy.…”

“… 1 The challenges include accessing the biliary limb, cannulation of the ampulla or hepaticojejunostomy, often in suboptimal orientations, and the need for alternative endoscopes other than the conventional duodenoscope. 2 The incidence of anastomotic stricture after hepaticojejunostomy reportedly ranges between 4% and 11.9%. 3 Balloon enteroscopy-assisted ERCP has made it possible to approach the surgically reconstructed intestine, and strictures can be treated endoscopically in a less invasive way.…”

“…In addition, challenges can include the inability to use common ERCP instruments, which may not be compatible with balloon enteroscopes. 2 Percutaneous transhepatic biliary drainage (PTBD) with balloon dilation and internal-external drainage placement represents the standard therapy. However, PTBD is associated with 2% to 14% morbidity, 5 , 6 poor long-term outcomes, and recurrence of stenosis in 34% of cases at 3 years.…”