Introduction
Postoperative bile duct-jejunal anastomosis stenosis has recently been treated by endoscopic ultrasound. Treatment has become possible, but treatment strategies and outcomes have not been clarified. In our hospital, EUS-guided Hepaticogastrostomy (EUS-HGS) followed by diagnosis with preoral cholangioscopy (POCS) and dilation with multiple plastic stents (PS). This time we will report on the long-term results of multiple stenting for Postoperative bile duct-jejunal anastomosis stricture.
Aims & Methods
To treat the postoperative bile duct-jejunal anastomosis stenosis, the first step is EUS-HGS procedure. We puncture B2 or B3. Then we perform dilation with balloon. Then we insert a single plastic stent. After 1 - 2 months from the initial puncture, we add a another PS. We exchange stents each 3 months, with POCS biopsy or EHL for stones. We go for remove the stents with more than 1-year stenting more than 2stents, evidence of no-malignancy, and obtain full explanation and consent from patient.
We followed up 28 cases in which EUS-HGS was attempted for postoperative bile duct-jejunal anastomosis stenosis between March 2017 and March 2022 until October 2022.
We defined the technical success as the success rate of EUS-BD procedure and the clinical success as the rate of the stent removal.
Results
Average age was 61year old, 16 cases were male, primary diseases were Congenital biliary dilatation(6), Congenital biliary atresia(5), IPMC(3), Cholecystitis(3), Pancreatic cancer(2), Alcohol cirrhosis(1), IPMA(1), Hepatoblastoma(1), Pancreatic cyst(1), Distal bile duct cancer(1), Hilar cholangiocarcinoma(1), Intrahepatic bile duct cancer (1), Metastasis of colorectal cancer(1), Gallbladder cancer(1). In 2 cases we cant success EHS-HGS. 4 cases of adverse events during EUS-HGS mediastinitis due to esophageal puncture (1), mild cholangitis (2), and bile leakage (1), all of which are conservatively mild. POCS was inserted in 22 cases. Time to insert POCS from EUS-HGS was 112days. In benign disease cases the period was 94 days and 74days in malignant cases. Biopsy was performed in 15 cases and, malignant finding was in 2cases. Including these 2cases, 5 cases was changed to SEMS because of malignant finding(CT, POCS biopsy, DB-ERC biopsy). Two cases was died before remove stent because not of the primary disease or anastomosis stricture.
As the technical success, in the benign stricture which passed over a year after EUS-HGS, stent removal was possible in 74% (14/19) . There were 5 cases that multiple stents cannot be removed even after more than one year has passed since they were placed. There reasons were, PS anastomosis not broken out (1), stone residue (1), no improvement in stenosis (1), stricture also in intrahepatic bile duct, and personal desire (1). The average period of multiple stenting was 484 days. The average period after stent removal was 738 days. In 3 cases the postoperative bile duct-jejunal anastomosis stricture recured and dranage with PTBD or EUS-HGS was implemented again. It took 278 days in average from stent remove to recure.
Conclusion
Multiple PSs stenting with EUS-HGS for Postoperative bile duct-jejunal anastomosis stenosis effects good, and the recurrence rate of stenosis is expected to be low. However, it is necessary to accumulate the number of cases and consider the results more over the long term.
Disclosure
Honoraria: FUJIFILM Corporation
Grants for commissioned/joint research: FUJIFILM Corporation, Boston Scientific Japan Corporation
Scholarship grants: Boston Scientific Japan Corporation