Obstructive jaundice after bilioenteric anastomosis: transhepatic and direct percutaneous enteral stent insertion for afferent loop occlusion

Abstract

Recurrent tumour after radical pancreaticoduodenectomy may cause obstruction of the small bowel loop draining the liver. Roux-loop obstruction presents a particular therapeutic challenge, since the postsurgical anatomy usually prevents endoscopic access. Careful multidisciplinary discussion and multimodality preprocedure imaging are essential to accurately demonstrate the cause and anatomical location of the obstruction. Transhepatic or direct percutaneous stent placement should be possible in most cases, thereby avoiding long-term external biliary drainage. Gastropexy T-fasteners will secure the percutaneous access and reduce the risk of bile leakage. The static bile is invariably contaminated by gut bacteria, and systemic sepsis is to be expected. Enteral stents are preferable to biliary stents, and compound covered stents in a sandwich construction are likely to give the best long-term results. Transhepatic and direct percutaneous enteral stent insertion after jejunopexy is illustrated and the literature reviewed.

Keywords: Anastomosis, Roux-en-Y; Cholestasis; Gastropexy; Jejunostomy; Palliation.

Fig. 1

Patient 1. Magnetic resonance cholangiopancreatography showing a patent choledochojejunostomy (arrow) with obstruction of the afferent loop (arrowheads).

Fig. 2

(A) Transhepatic cholangiogram confirms a tight stricture (arrow) with further narrowing distally (arrowhead). (B) Tortuosity of the loop made catheterization difficult. (C) A 22-mm ComVi stent after deployment with limited expansion across the stricture (arrow). The proximal end is positioned just below the anastomosis (arrowheads).

Fig. 3

Check cholangiogram showing decompression of the biliary tree and the free flow of contrast agent through the stent.

Fig. 4

Patient 2. US shows a dilated hepaticojejunostomy (arrow).

Fig. 5

Magnetic resonance cholangiopancreatography demonstrating the dilated Roux loop.

Fig. 6

(A) CT shows two limbs of the fluid-filled afferent loop (arrows) directly beneath the anterior abdominal wall. (B) The Roux loop is obstructed in the upper pelvis by a tumor nodule (arrow).

Fig. 7

"Harpon" T-fastener and insertion needle. The metal bar (arrow) retracts the stomach, and the cotton wool bud (arrowhead) is fixed against the skin after insertion.

Fig. 8

(A) Percutaneous puncture of the Roux loop. The T-fasteners (arrows) are evident above the needle. (B) Injection of contrast agent shows a massively dilated proximal loop with a tight stricture (arrow). (C) Deployed 22 mm Niti-S D-stent with limited initial expansion (arrow) but still allowing the free flow of contrast agent across the stricture.

Fig. 9

(A) After 24 hours there is further expansion (arrow). (B) Dilatation with a 12 mm balloon.

Fig. 10

3 days after drain removal, pus is seen draining from the puncture site (arrow) between the gastropexy sutures. This was successfully treated by applying a silver dressing (arrowheads).

Fig. 11

(A) CT performed 15 months after stent insertion shows air in both lobes of the liver (arrow), indicating stent patency. (B) However, some tumour ingrowth (arrow) into the uncovered stent is evident.