Forward-viewing echoendoscope is useful for recanalization of postoperative biliary anastomotic atresia in endosonography-guided biliary drainage

One possible cause of biliary peritonitis and stent migration as adverse events of transgastrohepatic endosonography-guided biliary drainage (EUS-BD) [ 1 ] is a puncture site in the stomach wall and liver that is not fixed. Magnetic compression anastomosis (MCA) is applied to fix two organs, the gastrointestinal tract and the bile duct [ 2 ] [ 3 ]. Herein, we present an alternative technique to fix these organs without MCA through recanalization of postoperative biliary anastomotic atresia with EUS-BD using a forward-viewing echoendoscope. A 78-year-old man who underwent pancreatoduodenectomy because of cholangiocarcinoma was admitted with retrograde cholangitis. We tried to insert internal–external drainage tubes as percutaneous transhepatic biliary drainage tubes; however, the guidewire could not be inserted through the bile duct owing to complete atresia of the anastomosis site ([ Fig. 1 ]). Fig. 1 Endoscopic image showing complete atresia of the anastomosis site between the bile duct and jejunum, which was covered by jejunal mucosa. We then performed EUS-BD with a forward-viewing echoendoscope (TGF-UC260 J, EU-ME1; Olympus Medical Systems, Tokyo, Japan) ([ Fig. 2 ]; [ Video 1 ]). We identified the anastomosis site by endoscopy and confirmed by endoscopic ultrasound that the guidewire that was inserted through a percutaneous transhepatic approach was in the bile duct. We punctured the bile duct at the anastomosis site with a puncture needle and placed the guidewire into the bile duct. Although we tried to dilate the bile duct with a balloon dilator, the device could not go through the needle tract. Therefore, the bile duct was dilated with a wire-guided diathermic dilator. We reinserted the balloon dilator and exchanged it initially for a plastic stent (QuickPlaceV; Olympus Medical Systems) ([ Fig. 3 ]) and subsequently for a wide-caliber stent, before adding another stent to dilate the recanalization route ([ Fig. 4 ]). No adverse events of EUS-BD were observed. One year after EUS-BD was performed, the patient was free from all stents ([ Fig. 5 ]). Fig. 2 Photograph of the forward-viewing echoendoscope (TGF-UC260 J, EU-ME1; Olympus Medical Systems, Tokyo, Japan). Video 1 A forward-viewing echoendoscope can enable a more vertical approach to the anastomosis site and help establish a rigid connection between the jejunum and bile duct in endosonography-guided biliary drainage. Quality: mobile 360 480 720 Download Fig. 3 Endoscopic image immediately following the exchange of a balloon dilator with a 7-Fr straight plastic stent with a length of 5 cm. Fig. 4 Endoscopic image 5 months after endosonography-guided biliary drainage after the recanalization route had been dilated with 8.5-Fr and 7-Fr straight plastic stents with lengths of 5 cm. Fig. 5 Endoscopic image 1 year after endosonography-guided biliary drainage showing the recanalization route that remained open after the patient was free from all stents. A forward-viewing echoendoscope may allow us to approach the anastomosis site more vertically and shorten the puncture distance, contributing to the feasibility and safety of the procedure [ 4 ]. Endoscopy_UCTN_Code_TTT_1AS_2AD Endoscopy E-Videos https://eref.thieme.de/e-videos Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. This section has its own submission website at https://mc.manuscriptcentral.com/e-videos Publication History Article published online: 12 May 2020 © 2020. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany