Introduction

Hepaticojejunostomy anastomotic stricture (HJAS) is one of the common adverse events after bile duct reconstruction surgery, which is reported to occur in 3–13%. Endoscopic approach using BE-ERCP has become the first choice due to less invasiveness, and long-term resolution rate is reported 50-90%.

Aims & Methods

In order to treat symptomatic hepatico-jejunostomy anastomosis stenosis (HJAS), we firstly perform balloon dilation or plastic stent or fully covered self-expandable metallic stent (FCSEMS) by single balloon ERCP (SBE-ERCP) and secondary insert FCSEMS by EUS-BD, in cases of severe stenosis or non-canulation. Then we have investigated the efficacy of FCSEMS for HJAS. From January 2015 to December 2022, we have performed 698 procedures of SBE-ERCP in 348 cases and inserted FCSEMS in 37 cases with symptomatic HJAS (only benign cases, excluded malignancy). We have planned to deploy FCSEMS for 6 months and removed it after that. Then we investigated resolution rate of HJAS at removing FCSEMS, complication, and long-term resolution rate of HJAS after FCSEMS.

Results

Subjects were Male 26: Female 11 and Median age was 70 y/o. Surgical operation were 33 cases in B-Ⅱ+PPPD/ 4 cases in R-Y. Reason of deploying FCSEMS by SBE-ERCP were unresolved stenosis by balloon dilation or plastic stent (PS) in 29 cases. And FCSEMS for severe stenosis in 6 cases were inserted by direct EUS-Choledocho-jejunostomy (EUS-CJS) and undetectable HJA in 2 cases by Rendezvous EUS-HGS. Additionally, side by side PS were inserted in 32 cases. Finally total subjects were 36, except for 1 case not reached to 6 months. Although 1 FCSEMS migrated into intrahepatic bile duct, 21 FCSEMS were removed endoscopically and remaining 15 FCSEMS were spontaneously dislocated after resolving HJAS. Resolution rate of HJAS at removing FCSEMS were 92% (33/36). Remained 3 cases were treated by additional deploying FCSEMS for 141 days in average. In median 19.0 (0.4-69.1) months followed up period, complications were non-obstructive cholangitis in 8 cases which were treated conservatively and intrahepatic stone in 2 cases which were treated by SBE. Resolution rate of HJAS at 1, 2, 3 years was 100%, 100%, and 100%. Recurrent HJAS occurred in 1 case at 46 months and treated by re-FCSEMS for 189 days.

Conclusion

Treatment of HJAS by FCSEMS were effective in long term period. SBE, EUS-CJS, and EUS-HGS were complimentary each other.

Introduction

EUS-hepatico-gastrostomy(HGS) has become indispensable procedure in case of inaccessible cases due to malignant invasion to the duodenum etc. , failed ERCP cases, and failed cases after single balloon assisted ERCP(SBE-ERCP) in surgical altered anatomy.

Aims & Methods

From January, 2016 to April, 2024, we have performed EUS-HGS in 131(Male:79, Female 52, averaged age: 72) cases. The indication of EUS-BD was inaccessible to the duodenal papilla due to malignant invasion or failed cases of ERCP in cases of normal anatomy. In cases without duodenal invasion and intrahepatic bile duct dilatation, we perform EUS-CDS and we perform EUS-BD rendezvous in cases of accessible normal anatomy. And we performed EUS-HGS in remained cases. In surgical anatomy cases, we firstly perform SBE-ERCP, EUS-HGS were performed after failed SBE-ERCP. We have investigated the safety and usefulness of HGS.

Results

The subjects were consisted of malignant diseases (pancreatic cancer: 61(46.6%), biliary cancer: 20(15.3%), and others 35(26.7%) and benign disease (stenosis of bilio-jejunum anastomosis 7(5.3%), bile duct stone7(5.3%), primary sclerosing cholangitis 1(0.8%)). The reason for EUS-HGS were consisted of duodenal invasion 84 (64.1%) cases, inaccessible 21(16%), failed deep canulation 20(15.3%), others 6(4.6%). And normal anatomy cases were 90 (68.7%) and surgical anatomy 41(31.3%). Technical and clinical success was 128(97.7%) and 116(88.5%). The median procedure duration was 36 minutes (range 11-109). The used needle was 19 guage: 113(86.3%) and 22 guage: 18(13.7%). The puncturing branch was B3: 95(72.5%), B2: 35(26.7%), and B1: 1(0.8%). The averaged size of punctured branch was 5.0mm (range2.0-13.0). The dilation method was bougie: 97(74%), balloon: 21(16%), electrocautery: 6(4.6%), drill dilator: 5(3.8%), and not dilate: 2(1.5%). The used stent was plastic stent (PS): 105(80.2%) and covered metallic stent (CMS): 24(18.3%). The stent patency was PS: 120 days and CMS: 226 days (p=0.13). The early complication was peritonitis: 10(7.6%), bacteremia: 5(3.8%), cholangitis: 4(3.1%), bleeding: 2(1.5%), and migration: 3(2.3%). The multivariate analysis revealed only longer procedure duration (more than 36 min.) corelated to early complication(p=0.01).

Conclusion

EUS-HGS is safe and effective and essential for inaccessible cases, failed cases after ERCP and SBE-ERCP. And longer procedure duration corelated with early complication.

Clinical Case Summary

A 39 year old female had a routine laparoscopic cholecystectomy in 2017. An unexpected complication arose - a proximal bile duct injury, setting off a chain of events that would impact the patient's life for years to come. In the months that followed, recurrent bouts of cholangitis occurred. A hepaticojejunostomy biliary reconstruction was performed in 2018. However, hepatic cholangitis persisted. In 2021 and 2022, MRCP scans revealed biliary stasis, duct dilation, and a stricture at the hepaticojejunostomy site. A subsequent PTC confirmed these findings and led to drain placement. The treatment journey included internal and external biliary drain placements, repeated balloon dilations of the stricture, percutaneous transhepatic cholangioscopy to extract intrahepatic lithiasis, and insertion of a biodegradable biliary stent. Since the first PTC intervention, there have been no hospital admissions for cholangitis. Liver function tests showed improvement, and for five months following the biodegradable stenting, the condition remained stable. The patient now attends clinic visits and undergoes blood tests every three months. Long-term surveillance with regular imaging and blood work has been emphasized. The final diagnosis is recurrent biliary stricture secondary to proximal bile duct injury. Treatment, including hepaticojejunostomy, repeated PTC with balloon dilation, and biodegradable biliary stenting, has led to complete drainage of the biliary system. Ongoing follow-up remains crucial for monitoring the patient's progress and maintaining their health.
This case demonstrated how strictures and recurrent cholangitis complicate the management of BDIs after laparoscopic cholecystectomy. A customized and multidisciplinary approach to control chronic biliary disease was proven effective, as shown by the patient’s good outcome. Long-term follow-up and continued monitoring remain essential to ensure patient stability and prevent further complications.

References

1. Yang S, Hu S, Gu X, Zhang X. Analysis of risk factors for bile duct injury in laparoscopic cholecystectomy in China: A systematic review and meta-analysis. Medicine. 2022;101:30365. [DOI: 10.1097/md.0000000000030365]
2. Vincenzi P, Mocchegiani F, Nicolini D, Benedetti Cacciaguerra A, Gaudenzi D, Vivarelli M. Bile duct injuries after cholecystectomy: An individual patient data systematic review. J Clin Med. 2024;13:4837. [DOI: 10.3390/jcm13164837]

Introduction

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has become an indispensable examination in the clinical fields. Recently therapeutic EUS such as pseudocyst drainage, EUS-biliary drainage, and EUS-pancreatic duct drainage, etc. have become popular. In order to become a good endosonographer, it has been believed that the learning of EUS-FNA takes long time and certain number of case experiences are essential. And it is also difficult to learn EUS/EUS-FNA without instructors. Furthermore, clinical cases are not enough for training young endosonographer. Then hands-on training with models are able to reduce the number of performing clinical Therapeutic EUS on training program.

Aims & Methods

Therefore, we have developed newly designed model for training therapeutic EUS procedure such as EUS-HGS and PFC drainage, conducted the trial of these models with trainees, and investigated its usefulness and limitations.
We have collaborated with Olympus Co. and made model for EUS-HGS by special plastic material (Century medical Co., Tokyo) and pseudocyst model by non-rupture-balloon (SB Kawasumi Co., Tokyo) which is 8cm in diameter. This balloon is filled by lubricant, and these models are put into water tank. We have tried this model at Kitasato Train-The-Trainer (TTT) and Changhai TTT with 26 trainees (11 for HGS and 15 for PFC). We have investigated whether all trainees can complete HGS and PFC drainage procedure (each 5 steps; identify target, needle puncture), GW insertion, dilation, and stenting) and measured these procedure step times. At first each trainee tried these models after simple explanation and they tried it as 2^ndtime after teaching tips and tricks. We have employed UCT-260 (Olympus Co., Tokyo) ,19G EUS-FNA needles and 7Fr plastic stent as a drainage tube.

Results

Concerning about PFC drainage, trainees completed the procedure 11/15(73%) at first try and 11/15(73%) at second time. At first try, 3 trainees completed up to 3rd step, not to 4th, 5thsteps, and at second try, 1 trainee still completed up to 3rd step, but 3 up to 4th step. Averaged time of 1^st try and 2^nd try is 780s vs 594s (p<0.001), respectively. Concerning about HGS model, trainees completed the procedure 11/11(100%) at first try and 11/11(100%) at second time. Averaged time of 1^st try and 2^nd try is 712s vs 490s (p<0.001), respectively. According to their impression, resistance of puncture and putting in a stent is less, compared with clinical cases, even though this model has resistance to pass through the gastric wall,PFC wall, and hepatic parenchyma. Trainees with less experience improved apparently, compared with trainees with more experience. However, it is very useful to understand the procedure of EUS-HGS and EUS-guided PFC drainage for the biggner of therapeutic EUS.

Conclusion

We concluded that newly designed EUS-HGS and pseudocyst model is useful to train the beginner, in order to understand the procedure. Furthermore, using these models, we can brush up their skill by repeating hands-on training.

Introduction

Management of poscholecystectomy complications has been variably discussed. Various options exist but the recent trend has been towards the endoscopic retrograde approach favoring a simultaneous diagnostic and therapeutic potential.

Aims & Methods

The outcome of endoscopic biliary dilatation and stent insertion for postoperative bile duct injuries was retrospectively evaluated.
Seventy-nine patients with biliary stenosis postcholecystectomy laparoscopic were included from January 2015 to December 2024. One to five stents were inserted for average of 12 months, with stent exchange every three months to avoid chlolangites caused by obstruction.

Results

Endoscopic stricture stent insertion successful was achieved in 76/76 (100%) patients. No procedure-related mortality was observed. The endoscopic therapy was feasible only in 76/76 the success rate was 100%. Endoscopic treatment was interrupted in three patients. Stricture relapse occurred in nine patients. Early complications occurred in three patients (1 perfuration, 1cholangites 1 stent migration) and stent occlusion that required early exchanges occurred in 6 patients.

Conclusion

Endoscopic retrograde cholangiopancreatography is a safe and feasible mode of therapy for patients presenting with suspected bile duct injuries. This form of intervention should be considered as the initial step in the diagnosis and treatment of postchlocystectom laparoscopic complications.

Disclosure

No conflict of interest

Introduction

Difficult bile stones (DBS) accounts for 10 to 15% of choledocholithiasis cases. In this setting different endoscopic techniques are available to obtain bile duct clearance. Of them endoscopic papillary large balloon dilation (EPLBD) demonstrated high rate of efficacy and is usually performed as a first step when DBS are encountered. However, EPLBD alters the anatomy and the functional role of major papilla potentially exposing patients to cholangitis. To date, few data are available in literature on the long-term consequence of EPLBD.

Aims & Methods

Aim of the study is to explore the long-term complications of EPLBD in terms of cholangitis and biliary recurrence. This is a multicenter retrospective study conducted within 33 centers. Adult patients who underwent to EPLBD (balloon diameter ≥12 mm) and obtained complete bile duct clearance in one or more endoscopic sessions were included in the study. Patients with surgical altered anatomy and those with orthotopic liver transplantation were excluded from the study. Primary outcome of the study was the rate of cholangitis; secondary outcome was endoscopic reintervention after EPLBD.

Results

1221 patients (654 female) with a median age of 77 yo (IQR 68-84) were included in the study. EPLBD was performed after previous failed ERCP standard treatments in 43.7% of cases. Indication for EPLBD was a single or double large stone in 51.8% of patients or multiple stones in 48.2% of patients with a median common bile duct (CBD) diameter of 15 mm (IQR 12-18). Large balloon dilation was performed at a median diameter of 13 mm (IQR 12-15) and CBD clearance was obtained with only one EPLBD session in 81.3% of patients. Assessment of CBD clearance was evaluated in 93% of cases with cholangiography and in the remaining of cases with cholangioscopy or cross-sectional imaging. Intra-procedural and short-term adverse events (AEs) were recorded in 3.9% and 8% of patients respectively. During a median follow-up time of 921 days (IQR 513-1644) 143 patients (11.7%) experienced at least one episode of cholangitis that have occurred after a median time of 293 days from EPLBD (IQR 133-553 days). Cholangitis was caused by stones recurrence in 76% of cases. Cholangitis was managed in the majority of cases (83.5%) with ERCP and in the remaining with conservative antibiotic therapy. Global rate of biliary recurrence with need of ERCP was recorded in 16% of patients. At Kaplan-Meier analysis the risk of cholangitis or biliary recurrence was homogeneous during follow-up time and was not affected by dilator balloon diameter (more or less than 15 mm). At multivariate Cox regression analysis, risk factors for cholangitis were a previous ERCP before EPLBD (HR 95%CI 1.65; 1.16 to 2.34), presence of multiple biliary stones (HR 95%CI 1.67;1.18 to 2.36) and stone recurrence during follow-up (HR 95%CI, 2.86; 1.61 to 5.08) whereas cholecystectomy status was not associated to long-term complications.

Conclusion

Cholangitis is not an uncommon long-term complication of EPLBD. The risk of cholangitis is homogeneous during follow-up time and the major determinants of cholangitis are previous ERCP before EPLBD, the presence of multiple biliary stones and the occurrence of stone recurrence during follow-up.