Endoscopic ultrasound-guided antegrade dilation of a stenosed hepaticojejunostomy.

Endoscopic dilation of a strictured hepaticojejunostomy can be performed through an access or afferent loop using a balloon enteroscope or a pediatric colonoscope; however, these canbe cumbersomeprocedures. Alternatively, a percutaneous approach may be utilized, but is associated with significant morbidity because of the requirement for external drainage catheters. Recently, endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) or therapy has been successfully used when retrograde access has failed [1–3]. Here we describe a case involving a stenosed hepaticojejunostomy that was treated by EUS-guided antegrade balloon dilation. To the best of our knowledge, this is only the second such case reported in the literature [4]. A 43-year-old woman presented with repeated episodes of cholangitis over an 18-month period secondary to stenosis of a hepaticojejunostomy that had been created for a previous bile duct injury (●" Fig.1). The papilla was inaccessible endoscopically using a double balloon enteroscope because of a long afferent loop and adhesions. The patient was unwilling to undergo percutaneous transhepatic biliary drainage (PTBD). EUS-guided left duct puncture was therefore performed via a transgastric approach using a therapeutic linear-array echo endoscope (EG530UT; Fujifilm Corporation, Tokyo, Japan). The peripheral intrahepatic left duct, with a diameter of 3.5mm, was identified (●" Fig.2a) and was punctured using a 19-gauge needle (Echo-tip Ultra; Cook Endoscopy, Winston-Salem, North Carolina, USA; ●" Fig.2b). EUS-guided cholangiography showed mild dilatation of the intrahepatic biliary radicles with a focal anastomotic stricture (●" Fig.3). A 0.032-inch, 260-cm hydrophilic guide wire (Terumo Corporation, Tokyo, Japan) was passed through the needle and across the stricture. The tractwasdilatedover the wire using an ultra-tapered 6-Fr catheter (Cook Endoscopy). The guide wire was then exchanged for a stiffer 0.035-inch wire (Visiglide; Olympus Corporation, Tokyo, Japan). Fig.1 Magnetic resonance cholangiopancreatography (MRCP) in a 43-year-old woman with cholangitis showing mild dilatation of the intrahepatic biliary radicles and stenosis of the hepaticojejunostomy that had been created for a previous bile duct injury.