Endoscopic transhepatic cholangiography with antegrade transanastomotic stent placement

Ryan Law, DO, from the Division of Gastroenterology at the University of Michigan in Ann Arbor, Michigan, USA, shares this case from the VideoGIE section, “Endoscopic transhepatic cholangiography with antegrade transanastomotic stent placement in a liver transplantation patient with Roux-en-Y hepaticojejunostomy.”

Our case describes the endoscopic treatment of a hepaticojejunostomy stricture in an adult patient with developmental delay who underwent a left lobe, living related donor liver transplantation with Roux-en-Y hepaticojejunostomy (HJ) for biliary atresia as a child. She previously underwent percutaneous biliary drainage; however, the catheter was poorly tolerated leading to premature removal. Attempts to access the stricture with single-balloon enteroscopy were unsuccessful. Given the complexity of this case and the limited therapeutic options available, EUS with antegrade balloon dilation and stent placement was performed through biliary access obtained via gastric puncture. After 6 months of therapy, the stents 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, and allow for therapeutic interventions in select patients.

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.

This case demonstrates a successful endoscopic solution in a patient with very limited options. Double balloon enteroscopy to access the hepaticojejunostomy could be attempted in similar scenarios but was unavailable in this instance. It should be noted that the patient had a left lobe liver transplant making access to the biliary tree possible. In contrast, this technique is likely more challenging in patients with a right lobe graft.

Find more VideoGIE cases online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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