Outcomes of patients with hepaticojejunostomy anastomotic strictures undergoing endoscopic and percutaneous treatment

Abstract

Background: Rising hepaticojejunostomy surgeries have led to an increase in benign strictures of the anastomosis. Double balloon enteroscopy assisted ERCP (DBE-ERCP) and percutaneous transhepatic biliary drainage (PTBD) are treatment options however there is lack of long-term outcomes, with no consensus on management. We performed a retrospective study assessing the outcomes of patients referred for endoscopic management of hepaticojejunostomy anastomotic strictures (HJAS). Methods: All consecutive patients at a tertiary institution underwent endoscopic intervention for suspected HJAS between 2009 and 2021 were enrolled. Results: 82 subjects underwent DBE-ERCP for suspected HJAS. Technical success was 77% (63/82). A HJAS was confirmed in 41 patients. Clinical success of DBE-ERCP +/- PTBD was 71% (29/41). DBE-ERCP alone achieved clinical success in 49% (20/41). PTBD was required in 49% (20/41). Dual therapy was required in 22% (9/41). Those with liver transplant had lower technical success compared to other surgeries (72.1% vs 82.1% p=0.29), lower clinical success with DBE-ERCP alone (40% vs 62.5% p=0.16) and required more PTBD (56% vs 37.5% p=0.25). All those with ischemic biliopathy (n=9) required PTBD for clinical success, required more DBE-ERCP (4.4 vs 2.0, p=0.004), more PTBD (4.7 vs 0.3, p<0.0001), longer treatment duration (181.6 vs 99.5 days p=0.12) and had higher recurrence (55.6% vs 30.3% p=0.18) compared to those with HJAS alone. Liver transplant was the leading cause of ischemic biliopathy (89%). The overall adverse event rate was 7%. Conclusion: DBE-ERCP is an effective diagnostic and therapeutic tool in those with altered gastrointestinal anatomy and is associated with low complication rates.

Transluminal antegrade drill dilation technique for hepaticojejunostomy stricture with cholangioscopic evaluation (with video)

“…In the case of surgically altered anatomy, there are two access routes to a biliary lesion: percutaneous and endoscopic. In a recent study, Choi et al evaluated the outcomes of patients with HJS who underwent PTBD or DB-ERCP 8 . Among these patients, 82 underwent DB-ERCP for suspected HJS, in whom the endoscope could reach the desired site in 63 (technical success rate, 77%); and 41 patients were diagnosed with HJS.…”

“…As HJS treatment techniques, balloon dilation, plastic stent, and metal stent deployment have been reported 2 8 9 10 11 15 16 17 18 19 22 23 24 . Although balloon dilation is a simple procedure with a high technical success rate, the restenosis rate has been reported to range from 34.3% to 52.2% 22 23 .…”

“…As recent technological developments in diagnostic tools such as endoscopic ultrasound (EUS) begin to have an impact on the early detection of pancreato-biliary cancer and on patients considered eligible for neoadjuvant chemotherapy, the number undergoing pancreaticoduodenostomy (PD) or pylorus-preserving PD may increase, and therefore, the number complicated by HJS may also increase 2 3 4 5 6 . HJS is traditionally treated by the percutaneous transhepatic approach (PTBD) 7 8 ; however, PTBD has several limitations, including external drainage, which may lead to prolonged hospitalization, and the risk of self-removal of the tube. Double-balloon enteroscopy endoscopic retrograde cholangiopancreatography (DB-ERCP) has also been reported as a treatment option for HJS 8 9 10 11 but has the disadvantages of prolonged procedure time and a relatively low technical success rate.…”

“…HJS is traditionally treated by the percutaneous transhepatic approach (PTBD) 7 8 ; however, PTBD has several limitations, including external drainage, which may lead to prolonged hospitalization, and the risk of self-removal of the tube. Double-balloon enteroscopy endoscopic retrograde cholangiopancreatography (DB-ERCP) has also been reported as a treatment option for HJS 8 9 10 11 but has the disadvantages of prolonged procedure time and a relatively low technical success rate. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has recently been reported as an alternative technique for failed ERCP and patients in whom PTBD is contraindicated 12 13 .…”

The Role of Cholangioscopy in Biliary Diseases

“…Post-orthotopic liver transplantation (OLTx) BSs are a common complication that may occur in both preserved anatomies (stricture at the level of biliary anastomosis of the recipient and donor) and altered anatomies (stricture at the level of hepatic-jejunal anastomosis) and may require multiple endoscopic interventions (e.g., endoscopic multistenting) [ 91 ]. However, endoscopic multiple access in the case of an altered anatomy could be time consuming and challenging [ 92 ]. A recent retrospective study demonstrated the efficacy of PC for the treatment of post-OLTx BSs, with failure in only 2 out of 25 patients [ 93 ].…”