Post written by Akihiko Kida, MD, PhD, from the Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, Hakusan, Japan, and the Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Japan.

The number of patients with biliopancreatic malignancies with long-term survival after surgery has increased with advances in chemotherapy, and there have been many opportunities to treat benign anastomotic stenosis.

Benign choledochojejunal anastomotic stenosis (bCJS) is one of the late adverse events of biliary reconstruction surgery. Bile duct stones (BDSs) with bCJS are characterized by surgically altered anatomy, stones located above a stricture, and intrahepatic stones. BDSs with these 3 conditions are extremely difficult to treat endoscopically. Although studies have performed endoscopic interventions for bCJS, few have used endoscopic interventions for BDSs with bCJS.

With bCJS, stricture resolution is achieved with balloon dilation, balloon dilation plus placement of a plastic stent, and temporary placement of a fully covered self-expandable metal stent (FCSEMS). Mechanical or electrohydraulic lithotripsy under cholangioscopy is performed to remove large and/or multiple BDSs. By combining these techniques, endoscopic interventions for BDSs with bCJS may become possible. Therefore, we retrospectively investigated the efficacy and long-term outcomes of endoscopic interventions for BDSs with bCJS.

Endoscopic interventions (dilation of the choledochojejunal anastomotic site [CAS] and BDS removal) were successfully performed in 16 of 17 patients (94%). Ten patients underwent successful balloon dilation at the CAS. (Successful balloon dilation was defined as balloon dilation to the diameter of the bile duct above the CAS.) Waist disappearance was achieved in 2 patients (20%). Six patients had a FCSEMS placed at the CAS, and stricture resolution was achieved in 6 patients (100%). BDSs were removed after balloon dilation or FCSEMS removal, and 6 of 16 patients (38%) were treated with a combination of lithotripsy and 5 (31%) with peroral direct cholangioscopy (PDCS). One patient with PDCS underwent balloon dilation, and 4 underwent FCSEMS placement at the CAS.

Regarding adverse events, perforation at the CAS by balloon dilation occurred in 1 patient, who improved with conservative treatment. The median follow-up was 3701 days. Nine of 16 patients (56%) had recurrence, which was common in patients not treated with the combination of PDCS at BDS removal (P = .022) and those without waist disappearance at the CAS by balloon dilation (P = .035).      

In conclusion, endoscopic interventions for BDSs with bCJS were useful, with a high success rate and safety. Long-term follow-ups showed frequent recurrences. For dilation of the CAS, FCSEMS placement was simpler and more useful than balloon dilation because balloon dilation with waist disappearance was achieved in only 20% of patients, but stricture resolution was achieved in all patients with FCSEMS placement, and FCSEMS placement did not affect the degree of dilation at the CAS, such as waist disappearance at the CAS, by balloon dilation.

Therefore, sufficient dilation at the CAS by FCSEMS placement and the combination of PDCS at BDS removal are important to prevent recurrence. If these endoscopic interventions are technically difficult, BDS removal with waist disappearance at the CAS by balloon dilation may be effective.

Graphical abstract

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