Endoscopic ultrasound-guided choledochojejunostomy with a forward-viewing echoendoscope for severe benign bilioenteric stricture in a patient with Child’s resection

tomy with a forward-viewing echoendoscope for severe benign bilioenteric stricture in a patient with Child’s resection Anastomotic strictures occurring after choledochojejunostomy have generally been treated by a percutaneous approach. A recent study reported that good outcomes were obtained after balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography [1]. A number of procedures have been reported to be useful, including endoscopic ultrasound (EUS)-guided hepaticojejunostomy combined with antegrade stent placement [2], EUS-guided trans-hepatic antegrade balloon dilation [3], and EUS-guided choledochojejunostomy [4]. We describe our experiencewith a patient in whom we directly inserted a forwardviewing echoendoscope (TGF-UC260J; Olympus, Tokyo, Japan) [5], which punctured the bile duct at a hepaticojejunal anastomotic site. We then successfully placed a metal stent in retrograde fashion. The patient was a 74-year-old man with pancreatic cancer who had undergone pylorus-preserving pancreaticoduodenectomy and a modified Child’s resection. However, a stricture developed 11months after surgery. Retrograde stent placement with a single-balloon enteroscope and antegrade stent placement with a percutaneous cholangioscope failed because a guidewire could not pass through the stricture. A cholangiogram obtained during percutaneous trans-hepatic biliary drainage (PTBD) showed that the anastomotic site was completely occluded (●" Fig.1). A forward-viewing echoendoscope reached the hepaticojejunal anastomosis in 17 minutes. The bile duct was confirmed through an anastomotic stricture measuring about 10mm and was punctured with a 19-gauge needle (●" Fig.2). A guidewire was then placed (●" Video1). Subsequently, the anastomotic site was dilated with a 6-Fr diathermic dilator, and a 4-cm partially covered metal stent was placed in 35 minutes (●" Video2). There were no procedural complications. The left and right bile ducts were confirmed to be free of occlusion on PTBD cholangiography (●" Fig.3). The patient was discharged 2 days after treatment. Our results confirm that EUS-guided choledochojejunostomy performed with a forward-viewing echoendoscope is a new treatment option for patients with severe bilioenteric strictures.