PTC guided Rendezvous for Cholangitis in a Case of Anastomotic Stricture of Hepatico-duodenostomy

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:-

Quality in Endoscopy: ERCP, Munich 2011
Medical journal armed forces india 68 (2012) 299e303
Judah JR, Draganov PV. Endoscopic therapy of benign biliary strictures. World J Gastroenterol. 2007;13(26):3531e3539