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Novel transluminal treatment protocol for hepaticojejunostomy stricture using covered self-expandable metal stent

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Abstract

Background

Hepaticojejunostomy anastomotic stricture (HJS) is a rare complication after pancreatoduodenostomy. However, the rate of HJS may be increased with the expansion of operative indications, such as intraductal papillary mucinous neoplasm. Recently, the indications for EUS-guided biliary drainage to treat benign biliary disease have expanded. Recently, novel transluminal treatment protocol has been established in our hospital. The aim of this study was thus to evaluate the technical feasibility and safety of our treatment protocol.

Patients and method

Consecutive patients with complications of HJS between January and December 2018 were enrolled in this study. EUS-guided hepaticogastrostomy (HGS) is firstly performed. After 7 days to create the fistula, HGS stent is removed. HJS is transluminally evaluated by a cholangioscope, and antegrade balloon dilation is attempted. After 3 months, if HJS is still presence, antegrade stent deployment is performed using a covered metal stent. Also, after 1 month, antegrade stent removal is transluminally performed.

Results

Among total 29 patients, 14 patients were underwent antegrade metal stent deployment. The technical success rate of antegrade stent deployment was 92.9%. Median period of stent placement was 30.5 days (range 28–38 days), and transluminal stent removal was successfully performed in all patients. During follow-up (median 278 days; range 171–505 days), recurrence of HJS was seen in 2 patients. Severe adverse events were not seen in any patients during follow-up period.

Conclusion

Transluminal stent deployment for HJS under EUS-guidance appears feasible and safe, although further study with a larger sample size and longer follow-up is warranted.

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Author information

Correspondence to Takeshi Ogura.

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Disclosures

Takeshi Ogura, Nobu Nishioka, Masanori Yamada, Tadahiro Yamada, Saori Ueno, Jyun Matsuno, Kazuya Ueshima, Yoshitaro Yamamoto, Atsushi Okuda, and Kazuhide Higuchi have no conflicts of interest or financial ties to disclose.

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Supplementary file1 (MP4 66061 kb). Video 1 After guidewire deployment across the hepaticojejunostomy stricture, the stent delivery system is inserted into the hepaticojejunostomy stricture site. Stent release is carefully performed, and antegrade stent deployment is performed. Finally, a plastic stent is deployed from the intrahepatic bile duct to the stomach

Supplementary file2 (MP4 59793 kb). Video 2 After the double guidewire deployment is performed through the antegrade metal stent, the modified ERCP catheter is inserted over the guidewire. Then, the forceps biopsy device is inserted through the ERCP catheter. The antegrade stent is grasped, and removed through the EUS-HGS route. If the antegrade stent is dislocated with the fistula, because fit alignment is easy, a larger forceps biopsy device can be inserted. Finally, antegrade stent removal is successfully performed

Supplementary file1 (MP4 66061 kb). Video 1 After guidewire deployment across the hepaticojejunostomy stricture, the stent delivery system is inserted into the hepaticojejunostomy stricture site. Stent release is carefully performed, and antegrade stent deployment is performed. Finally, a plastic stent is deployed from the intrahepatic bile duct to the stomach

Supplementary file2 (MP4 59793 kb). Video 2 After the double guidewire deployment is performed through the antegrade metal stent, the modified ERCP catheter is inserted over the guidewire. Then, the forceps biopsy device is inserted through the ERCP catheter. The antegrade stent is grasped, and removed through the EUS-HGS route. If the antegrade stent is dislocated with the fistula, because fit alignment is easy, a larger forceps biopsy device can be inserted. Finally, antegrade stent removal is successfully performed

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Ogura, T., Nishioka, N., Yamada, M. et al. Novel transluminal treatment protocol for hepaticojejunostomy stricture using covered self-expandable metal stent. Surg Endosc (2020) doi:10.1007/s00464-020-07381-2

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Keywords

  • EUS
  • EUS-HGS
  • Hepaticojejunostomy stricture
  • Endoscopic ultrasound-guided biliary drainage
  • ERCP