• 58 year old female
  • Recurrent jaundice (Total bilirubin – 8 mg %), recurrent fever with chills
  • known case of anastomotic stricture of the hepatico – duodenostomy site
  • EUS revealed dilated CHD and IHBR without any obvious hypo echoic mass lesion or stones.
  • Duodenoscopy- Hepatico-duodenostomy opening was identified in the duodenal bulb which appeared extremely small and edematous
  • Despite repeated attempts cannulation through the duodenal route was not possible
  • PTC rendezvous- A guide wire was passed through PTC route and sequential balloon dilatation was carried out of the stricture with an 8 mm balloon at 8 ATM pressure
  • Cholangiogram- Dilated bile duct with dilated right and left hepatic ductal system and a dominant narrowing at the anastomotic site
  • A 7 Fr double pigtail stent was placed in the right ductal system and a 5 Fr Teflon stent was placed in the left ductal system
  • Free flow of bile was seen from the placed stent at the end of the procedure.

EXPERT COMMENTS:-

  • In patients following choledochoduodenostomy, recurrent ascending cholangitis due to bile reflux is noted in 0-4%.
  • PTC combined with ERCP for rendezvous techniques provides a non-surgical treatment for complex biliary strictures.1
  • Endoscopic therapy shares an equal long-term success rate in comparison with primary surgery and hence is the preferred approach for the management of benign biliary stricture.2

TAKE HOME MESSAGE:-

  • Sphincterotomy and endoscopic balloon dilatation alone is not a reliable method of treating benign strictures.3
  • Per cutaneous treatment by balloon dilatation followed by short- to intermediate term stent placement appears to provide a more durable result.3
  • In refractory cases placement of a fully covered self-expandable metallic stent can be considered.

REFERENCES:-

  1. Quality in Endoscopy: ERCP, Munich 2011
  2. Medical journal armed forces india 68 (2012) 299e303
  3. Judah JR, Draganov PV. Endoscopic therapy of benign biliary strictures. World J Gastroenterol. 2007;13(26):3531e3539
Severe anastomotic stricture of the hepatico-duodenostomy site

Severe anastomotic stricture of the hepatico-duodenostomy site

Cholangiogram showing complete obstruction at anastomotic site

Cholangiogram showing complete obstruction at anastomotic site

 

 

 

 

 

 

 

 

 

 

PTC guided cannulation of bile duct

PTC guided cannulation of bile duct

Balloon dilatation of stricture at anastomotic site

Balloon dilatation of stricture at anastomotic site

 

 

 

 

 

 

 

 

 

7 Fr double pig tail stent placement in right ductal system and 5 Fr Teflon stent in left ductal system

7 Fr double pig tail stent placement in right ductal system and 5 Fr Teflon stent in left ductal system

Fluoroscopy showing bilateral  stents in situ

Fluoroscopy showing bilateral stents in situ

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