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Review
. 2023 Sep 15;9(1):51-55.
doi: 10.1016/j.vgie.2023.09.007. eCollection 2024 Jan.

EUS-guided enteroenterostomy to facilitate peroral altered anatomy ERCP

Romik P Srivastava  1 , Robert A Moran  1 , B Joseph Elmunzer  1
Affiliations
Review

EUS-guided enteroenterostomy to facilitate peroral altered anatomy ERCP

Romik P Srivastava et al. VideoGIE. .

Abstract

Background and Aims: Definitive peroral endoscopic treatment of pancreaticobiliary pathology in patients with surgically altered anatomy has recently been made more feasible by the use of lumen-apposing metal stents (LAMS) to create bowel-to-bowel anastomoses. We aim to demonstrate 4 cases of non–gastric bypass Roux-en-Y anatomy for which an enteroenterostomy was created under EUS guidance to facilitate complex peroral ERCP.

Methods: Akin to EUS-directed transgastric ERCP, the approach to EUS-directed transenteric ERCP involves identification and expansion of the target bowel before transmural puncture and stent placement. Bowel irrigation is used to opacify and distend the pancreaticobiliary limb in reasonable proximity to the papilla or biliary-enteric anastomosis, which facilitates enteroenterostomy creation via LAMS placement. Peroral ERCP can be performed through anastomosis, generally using a therapeutic gastroscope, once the transmural tract has matured.

Results: In 4 cases of biliary obstruction, peroral ERCP was successfully performed after creation of an enteroenterostomy. In 3 of the 4 cases, target bowel opacification and distention were achieved by continuous irrigation through a previously placed percutaneous transhepatic cholangiography tube. In one case, a gastro-jejunostomy was created after irrigation of the target bowel loop via antegrade catheter advanced through a prior hepaticogastrostomy. No major adverse events occurred. In 2 of the 4 patients, the endoscopic objective (stone clearance) was met and the transenteric LAMS was removed. The other 2 patients are still undergoing serial ERCP.

Conclusions: EUS-guided enteroenterostomy permits safe and effective peroral ERCP, allowing for more efficient and effective treatment of pancreaticobiliary pathology in patients with surgically altered anatomy.

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Conflict of interest statement

The authors did not disclose any financial relationships.

Figures

Figure 1
Figure 1
Case 1: “Swirling” appearance of fluid within target jejunal loop during percutaneous transhepatic cholangiography tube irrigation, serving to localize and distend a suitable loop of small bowel in preparation for transmural, electrocautery-enhanced puncture.
Figure 2
Figure 2
Case 2: Two separate biliary-enteric anastomoses directly visualized after traversing through enteroenterostomy tract.
Figure 3
Figure 3
Case 2: Cholangioscopic (A), fluoroscopic (B), and endoscopic (C) images of the endoscopic management of hepaticolithiasis that is possible via enteroenterostomy.
Figure 4
Figure 4
Case 3: Endoscopic (A) and fluoroscopic (B) images of retrieving a distally migrated lumen-apposing metal stent using rat-tooth forceps.
Figure 5
Figure 5
Case 3: Guidewire access to small bowel during gastroscope withdrawal through enteroenterostomy to maintain access in the event of lumen-apposing metal stent migration.
Figure 6
Figure 6
Case 4: Endoscopic (A) and fluoroscopic (B) appearance of fresh gastro-jejunostomy.
See this image and copyright information in PMC

References

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