Post written by Mitsuru Okuno, MD, PhD, from the Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan.

We describe the case of occluded hepaticojejunostomy anastomosis (HJA) with a thick and hard fibrous membrane which was able to be safely resected under direct double-endoscopic views using a cholangioscope and enteroscope (short-type double balloon endoscope). This technique enabled the procedure to be performed with the cholangioscope via the percutaneous transhepatic biliary drainage route. After both endoscopes reached the occluded HJA, a needle precut knife was inserted via the enteroscope. When the needle was positioned in the correct direction toward the intrahepatic bile duct, the tip could be detected on the cholangioscope. The precut knife was set in the correct direction and resection of occluded HJA could be safely performed, after which the dilation balloon could pass and dilate the occluded HJA.

Endoscopic treatment for occluded HJA requires passing the endoscope through the anastomosis to insert the endoscopic retrograde cholangiopancreatography devices. However, when the membrane of the occluded HJA is thick and hard, it is extremely difficult to reopen the anastomosis under endoscopy because the opening direction is unknown.

We believe this case study makes a significant contribution for the completely obstructed HJA treatment because we describe a safe and effected treatment option for cases of completely obstructed HJA in which the fibrous membrane is thick and hard.

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