Gabriela F. Paduani

Double-balloon enteroscopy-assisted endoscopic retrograde cholangiography for the treatment of a strictured Roux-en-Y hepaticojejunal anastomosis.

A 49-year-old patient underwent cholecystectomy and Roux-en-Y hepaticojejunal anastomosis (● Fig.1) for Mirizzi’s syndrome. Jaundice, pruritus, choluria, and acholia developed 4 months later. The total serum bilirubin was 21mg/dL, and magnetic resonance cholangiopancreatography (MRCP) demonstrated intrahepatic bile duct dilation and anastomotic stricture. Double-balloon enteroscopy was performed, and the hepaticojejunal anastomosis was reached. A pinpoint anastomotic stricture was noted (● Fig.2). After diathermic debridement of the stricture, it was possible to traverse the stricture with a 0.035-inch hydrophilic tip guidewire (● Fig.3a,b). Cholangiography demonstrated a marked dilation of the intrahepatic biliary tree and a long (10-mm) anastomotic stricture. No filling defect compatible with stones was detected. A 12to 15-mm balloon (● Fig.4) was introduced over the wire, and the stenosis was successfully dilated to 15mm (● Fig.5). The serum bilirubin levels normalized in 5 days. Roux-en-Y hepaticojejunostomy stricture occurs in 10% to 30% of patients and requires prompt intervention [1]. Percutaneous and surgical approaches are the standard treatment options but may be associated with significant morbidity [2, 3]. In this scenario, balloon overtubeassisted enteroscopy provides an option to access the hepaticojejunal anastomosis. As illustrated by our case, the technical success rate of balloon overtube-assisted enteroscopy for postoperative retrograde cholangiography may be as high as 85%, and this technique should be considered as the first option for patients requiring postoperative endoscopic retrograde cholangiopancreatography (ERCP) [4–6].