Endoscopic and retrograde cholangiographic appearance of hepaticojejunostomy strictures: A practical classification

Abstract

AIM:To study the endoscopic and radiological characteristics of patients with hepaticojejunostomy (HJ) and propose a practical HJ stricture classification. METHODS:In a retrospective observational study, a balloon-assisted enteroscopy (BAE)-endoscopic retrograde cholangiography was performed 44 times in 32 patients with surgically-altered gastrointestinal (GI) anatomy. BAE-endoscopic retrograde cholangio pancreatography (ERCP) was performed 23 times in 18 patients with HJ. The HJ was carefully studied with the endoscope and using cholangiography. RESULTS:The authors observed that the hepaticojejunostomies have characteristics that may allow these to be classified based on endoscopic and cholangiographic appearances: the HJ orifice aspect may appear as small (type A) or large (type B) and the stricture may be short (type 1), long (type 2) and type 3, intrahepatic biliary strictures not associated with anastomotic stenosis. In total, 7 patients had type A1, 4 patients A2, one patient had B1, one patient had B (large orifice without stenosis) and one patient had type B3. CONCLUSION:This practical classification allows for an accurate initial assessment of the HJ, thus potentially allowing for adequate therapeutic planning, as the shape, length and complexity of the HJ and biliary tree choice may mandate the type of diagnostic and therapeutic accessories to be used. Of additional importance, a standardized classification may allow for better comparison of studies of patients undergoing BAE-ERCP in the setting of altered upper GI anatomy.

Prospective evaluation of spiral overtube–assisted ERCP in patients with surgically altered anatomy

“…However, all 3 patients with hepaticojejunostomies could be classified as having a type A1 hepaticojejunostomy. 19 (3) The study lacked a direct comparison with other methods of deep enteroscopy.…”

“…An endoscopic-radiologic classification of hepaticojejunostomy strictures has been recently proposed by Mönkemüller and Jovanovic. 19 This classification and data regarding the appearance of the hepaticojejunostomies were not originally included in our prospective study because that classification was not available at the time. However, all 3 patients with hepaticojejunostomies could be classified as having a type A1 hepaticojejunostomy.…”

Incidence of hepaticojejunostomy stricture after hepaticojejunostomy

“…Studies have reported success rates in patients who undergo reoperation for biliary-enteric anastomosis either after pancreatic surgery or bile duct injury, 7,8 however, endoscopic and percutaneous interventions are coming to the forefront. 9–11 While the need for repeat procedures with attendant morbidity may be expected, the incidence of these procedures remains unknown.…”

Rendezvous technique: double-balloon endoscopy and SpyGlass direct visualization system in a patient with severe stenosis of a choledochojejunal anastomosis

“…Locating the choledochojejunal anastomosis was difficult, but was successfully achieved by detecting the ulcer-scar-like lesion and a little biliary flow in the underwater observation (• " Video 1). However, the procedure failed because of a severe stenosis consisting of a long stricture with a small orifice in the choledochojejunal anastomosis, which was denoted a type A2 stricture in the classification of Mönke-müller and Jovanovic [1] and hindered the advancement of several devices. As an alternative, percutaneous transhepatic cholangiodrainage (PTCD) was applied, but this was again precluded by the severe stenosis.…”