VIDEOGIE Todd H. Baron, MD, G. S. Raju, MD, Editors for VideoGIE
Endoscopic transhepatic cholangiography with antegrade transanastomotic stent placement in a liver transplantation patient with Roux-en-Y hepaticojejunostomy
Figure 1. A, Endoscopic transhepatic cholangiogram demonstrating dilated left intrahepatic bile ducts and hepaticojejunostomy stricture. B, Placement of a fully covered self-expandable metal stent across the hepatogastrostomy to prevent bile leakage and allow for repeated endoscopic intervention.
A 20-year-old woman presented with abnormal liver chemistry levels. She had previously undergone left lobe liver transplantation from a living related donor, with Roux-en-Y hepaticojejunostomy (HJ) for biliary atresia. She had a history of a HJ stricture. Previously, percutaneous drainage was poorly tolerated because of underlying autism spectrum disorder, and single-balloon ERCP was unsuccessful. MRCP showed intrahepatic ductal dilation and stricture of the HJ. After informed consent was obtained from the patient’s guardian, a linear echoendoscope was advanced into the stomach. A left intrahepatic biliary radicle was accessed with an FNA needle. Cholangiography confirmed the MRCP findings (Fig. 1A). A guidewire was advanced into the intrahepatic system and subsequently across the HJ. Electrocautery was applied to create a hepaticogastrostomy with a cystotome. Sequential balloon dilation of the anastomosis and hepaticogastrostomy was performed. A fully covered self-expandable metal stent (FCSEMS) was deployed across the hepatogastrostomy to prevent bile leakage (Fig. 1B). A double pigtail stent was placed with the distal pigtail in the jejunum and proximal pigtail in the stomach (Video 1, available online at www. giejournal.org). During the repeated procedure 1 month later, the indwelling pigtail stent was removed and 3 stents were placed in parallel. After 6 months of therapy, the
www.giejournal.org
pigtail stents and FCSEMS were removed. Cholangiography demonstrated a widely patent hepaticojejunal anastomosis. Endoscopic transhepatic cholangiography may be a diagnostic alternative to percutaneous transhepatic cholangiography in patients with surgically altered anatomy, allowing access to the biliary tree for therapeutic interventions. DISCLOSURE Dr. Baron is a consultant and speaker for W. L. Gore and Boston Scientific; a consultant for, and recipient of research support from, Cook Endoscopy; and a consultant for Olympus America. All other authors disclosed no financial relationships relevant to this publication. None of the editors acted as reviewer of this article. Ryan Law, DO, Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA, Ian S. Grimm, MD, Todd H. Baron, MD, FASGE, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
http://dx.doi.org/10.1016/j.gie.2015.04.001
Volume
-,
No.
-
: 2015 GASTROINTESTINAL ENDOSCOPY 1
Endoscopic transhepatic cholangiography with antegrade transanastomotic stent placement in a liver transplantation patient with Roux-en-Y hepaticojejunostomy
Figure 1. A, Endoscopic transhepatic cholangiogram demonstrating dilated left intrahepatic bile ducts and hepaticojejunostomy stricture. B, Placement of a fully covered self-expandable metal stent across the hepatogastrostomy to prevent bile leakage and allow for repeated endoscopic intervention.
A 20-year-old woman presented with abnormal liver chemistry levels. She had previously undergone left lobe liver transplantation from a living related donor, with Roux-en-Y hepaticojejunostomy (HJ) for biliary atresia. She had a history of a HJ stricture. Previously, percutaneous drainage was poorly tolerated because of underlying autism spectrum disorder, and single-balloon ERCP was unsuccessful. MRCP showed intrahepatic ductal dilation and stricture of the HJ. After informed consent was obtained from the patient’s guardian, a linear echoendoscope was advanced into the stomach. A left intrahepatic biliary radicle was accessed with an FNA needle. Cholangiography confirmed the MRCP findings (Fig. 1A). A guidewire was advanced into the intrahepatic system and subsequently across the HJ. Electrocautery was applied to create a hepaticogastrostomy with a cystotome. Sequential balloon dilation of the anastomosis and hepaticogastrostomy was performed. A fully covered self-expandable metal stent (FCSEMS) was deployed across the hepatogastrostomy to prevent bile leakage (Fig. 1B). A double pigtail stent was placed with the distal pigtail in the jejunum and proximal pigtail in the stomach (Video 1, available online at www. giejournal.org). During the repeated procedure 1 month later, the indwelling pigtail stent was removed and 3 stents were placed in parallel. After 6 months of therapy, the
www.giejournal.org
pigtail stents and FCSEMS were removed. Cholangiography demonstrated a widely patent hepaticojejunal anastomosis. Endoscopic transhepatic cholangiography may be a diagnostic alternative to percutaneous transhepatic cholangiography in patients with surgically altered anatomy, allowing access to the biliary tree for therapeutic interventions. DISCLOSURE Dr. Baron is a consultant and speaker for W. L. Gore and Boston Scientific; a consultant for, and recipient of research support from, Cook Endoscopy; and a consultant for Olympus America. All other authors disclosed no financial relationships relevant to this publication. None of the editors acted as reviewer of this article. Ryan Law, DO, Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA, Ian S. Grimm, MD, Todd H. Baron, MD, FASGE, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
http://dx.doi.org/10.1016/j.gie.2015.04.001
Volume
-,
No.
-
: 2015 GASTROINTESTINAL ENDOSCOPY 1
