Successful endoscopic dilation of severe bilioenteric strictures with a wire-guided diathermic dilator and short-type single-balloon enteroscope.

Recently, balloon enteroscopy has made possible the use of endoscopic approaches to the surgically reconstructed intestine [1–4], so that hepaticojejunostomy strictures can be treated endoscopically. We describe the successful endoscopic dilation of a severe hepaticojejunostomy stricture with a wire-guided diathermic dilator (6-Fr, 180-cm Cysto-Gastro-Set; Endo-flex, Voerde, Germany) (●" Fig.1). A 66-year-old woman underwent pylorus-preserving pancreaticoduodenectomy for cancer of the pancreatic head. Cholangitis due to bilioenteric stricture developed at the third month after surgery. A short-type, single-balloon enteroscope (SIF-Y0004V01; Olympus Medical Systems, Tokyo, Japan) was used to perform balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography (ERCP). A 0.025-inch guidewire could pass through the stricture, but an ERCP imaging catheter with a tapered tip, 1.8 to 2.3mm in diameter (MTW Endoskopie, Wesel, Germany), and a 6-Fr Soehendra Biliary Dilation Catheter (Cook Medical, Winston-Salem, North Carolina, USA) could not. A guidewire was placed in a hepatic duct, and the anastomotic stricture was electrically dilated with a 6-Fr Cysto-Gastro-Set. After the dilation procedure, an imaging catheter could be passed through the stricture. The anastomosis was dilated with a 6.8-FrQuantumTTCBiliary BalloonDilator 6mm in diameter (QBD-6X3; Cook Medical), after which the cholangitis decreased (●" Video 1). Therewere no adverse events. The stricture was classified as a type A1 stricture according to the classification of Mönkemüller & Jovanovic [4]. In patients who undergo balloon enteroscope-assisted ERCP for hepaticojejunostomy strictures, a tangential approach to the stricture site is often used. When a needle-knife is used, it is difficult to perform coaxial dilation from a tangential approach (●" Fig.2b); this technique has caused anastomotic perforation [5] and so is not considered optimal. We therefore use a 6-Fr Cysto-Gastro-Set for the endoscopic dilation of anastomotic strictures (●" Fig.2a), which facilitates dilation along the same axis as the guidewire [5]. Our results suggest that a 6-Fr wire-guided diathermic dilator may be useful for anastomotic dilation in patients with severe hepaticojejunostomy strictures.