EUS hepaticogastrostomy for bilioenteric anastomotic strictures: a permanent access for repeated ambulatory dilations? Results from a pilot study

Abstract

Background and study aims: Postsurgical benign bilioenteric anastomotic strictures are a major adverse event of biliary surgery and endoscopic treatment, including endoscopic retrograde cholangiopancreatography (ERCP), is challenging in this setting. We present an innovative approach to treating this complication.

Patients and methods: Patients underwent endoscopic ultrasound (EUS)-hepaticogastrostomy (HG) to treat nonmalignant biliary obstructions. A first endoscopy was performed to create the hepaticogastrostomy and to drain the biliary tree. The second step had a therapeutic purpose: antegrade dilation of the anastomosis.

Results: Four men and three women with benign bilioenteric anastomotic strictures were included. Patients presented with jaundice or recurrent cholangitis. A fully covered HG stent was successfully deployed during the first endoscopy. During the second step, repeat antegrade dilation was performed through the HG in four cases (1 - 4 dilations) followed by double pigtail stenting in three cases. In three other patients, the stenosis was not crossable and a double pigtail stent was placed to maintain biliary drainage. All patients had symptom relief at the end of follow-up (45 weeks, range 33 - 64).

Conclusions: Dilation of anastomotic stenosis through a hepaticogastrostomy is feasible and may provide permanent biliary drainage or recurrent access to the biliary tree in patients with altered anatomy. Double pigtail stents might prevent migration.

Fig. 1 a

First endoscopic step. Endoscopic view of deployment of a fully covered metallic stent during hepaticogastrostomy. b Second endoscopic step. Fluoroscopic view of guidewire and dilation balloon being positioned within the hepaticojejunal anastomotic stricture. c Second endoscopic step. Fluoroscopic view of anastomosis dilation. Balloon inflated. d Second endoscopic step. Fluoroscopic view of deployment within the anastomotic stricture of a second double pigtail stent, with one end in the jejunum and the other end in the gastric lumen.