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Percutaneous transhepatic cholangioplasty to treat biliary strictures after biliary-enteric anastomosis
This is the case of a 50-year-old female patient presenting with a bilio-enteric anastomosis stricture caused by a bile duct injury during a cholecystectomy 10 years ago. The patient presents with multiple episodes of cholangitis treated by antibiotics, causing multiple hospital admissions. Blood test assessment demonstrates high levels of alkaline phosphatase. Her magnetic resonance cholangiopancreatography showed a stricture at the level of the hepaticojejunal anastomosis as well as mild intrahepatic biliary duct dilatation. An endoscopic approach was not suitable for this patient, because of the anatomical disturbance induced by the bilio-enteric surgical reconstruction. A percutaneous balloon catheter dilatation strategy was adopted. After two previous cholangioplasty sessions, a final session is presented here. The total duration of the last procedure was less than 1 hour, and a final stricture dilatation was achieved. After 24 hours of the final procedure, the biliary catheter was removed and the patient was discharged home without any complications.
ME Gimenez, A Garcia
Surgical intervention
6 months ago
241 views
2 likes
0 comments
13:34
Percutaneous transhepatic cholangioplasty to treat biliary strictures after biliary-enteric anastomosis
This is the case of a 50-year-old female patient presenting with a bilio-enteric anastomosis stricture caused by a bile duct injury during a cholecystectomy 10 years ago. The patient presents with multiple episodes of cholangitis treated by antibiotics, causing multiple hospital admissions. Blood test assessment demonstrates high levels of alkaline phosphatase. Her magnetic resonance cholangiopancreatography showed a stricture at the level of the hepaticojejunal anastomosis as well as mild intrahepatic biliary duct dilatation. An endoscopic approach was not suitable for this patient, because of the anatomical disturbance induced by the bilio-enteric surgical reconstruction. A percutaneous balloon catheter dilatation strategy was adopted. After two previous cholangioplasty sessions, a final session is presented here. The total duration of the last procedure was less than 1 hour, and a final stricture dilatation was achieved. After 24 hours of the final procedure, the biliary catheter was removed and the patient was discharged home without any complications.
EUS gastrojejunal anastomosis with HOT AXIOS® stent after Whipple pancreatectomy, filling blind loop through percutaneous transhepatic biliary drainage
A 67-year-old woman underwent a Whipple pancreatectomy for cancer one year earlier. She was readmitted to hospital for abdominal pain and subocclusion with jaundice. CT-scan showed a dilatation of the jejunal stump with associated biliary tree dilatation. Percutaneous biliary transhepatic drainage (PBTHD) was performed and a stenosis was diagnosed in the afferent loop, accountable for subocclusion and secondary jaundice. Two double pigtails were delivered by the interventional radiologist through PBTHD across the jejunal stricture without resolution of symptoms. Biliary drainage was left in place causing patient discomfort. EUS gastrojejunal anastomosis (GJA) using the HOT AXIOS® stent was attempted in order to bypass the stricture. EUS allows to find the jejunal stump, detected by mechanical staple line visualization. Additionally, the blind loop was detected as it was filled up with liquid and contrast through the PBTHD. The HOT AXIOS® stent was delivered without any complications (VIDEO). Afterwards, flow of bile and liquid was observed through the lumen-apposing metal stent (LAMS). PBTHD was immediately removed. Recovery was uneventful and the patient was discharged on a normal diet with no pain on the following day. EUS-GJA via a LAMS is a well-described technique in experts’ hands (Technical review of endoscopic ultrasonography-guided gastroenterostomy in 2017. Itoi T, Baron TH, Khashab MA, et al. Dig Endosc 2017;29:495-502). Special skills and techniques are necessary in order to recognize the exact small bowel loop to puncture (Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Tyberg A, Perez-Miranda M, Sanchez-Ocaña R et al. Endosc Int Open 2016;4:E276-81). In that case, we show that filling this loop using a previous transhepatic access should be considered an alternative in case of alterated anatomy. Also direct EUS transgastric injection of contrast medium in the dilated biliary tree to fill up the jejunal stump could be considered an option to perform GJA by a single operator in a single session after safely recognizing the right loop. In addition, fluoroscopy helps to detect the exact loop puncture site. In conclusion, GJA using a LAMS is feasible, safe and useful, and transhepatic injection of liquid and contrast medium helps to adequately recognize the jejunal stump after biliopancreatic surgery.
Gf Donatelli, G Pourcher, D Fuks, S Perretta, B Dallemagne, M Pizzicannella
Surgical intervention
6 months ago
111 views
2 likes
0 comments
02:30
EUS gastrojejunal anastomosis with HOT AXIOS® stent after Whipple pancreatectomy, filling blind loop through percutaneous transhepatic biliary drainage
A 67-year-old woman underwent a Whipple pancreatectomy for cancer one year earlier. She was readmitted to hospital for abdominal pain and subocclusion with jaundice. CT-scan showed a dilatation of the jejunal stump with associated biliary tree dilatation. Percutaneous biliary transhepatic drainage (PBTHD) was performed and a stenosis was diagnosed in the afferent loop, accountable for subocclusion and secondary jaundice. Two double pigtails were delivered by the interventional radiologist through PBTHD across the jejunal stricture without resolution of symptoms. Biliary drainage was left in place causing patient discomfort. EUS gastrojejunal anastomosis (GJA) using the HOT AXIOS® stent was attempted in order to bypass the stricture. EUS allows to find the jejunal stump, detected by mechanical staple line visualization. Additionally, the blind loop was detected as it was filled up with liquid and contrast through the PBTHD. The HOT AXIOS® stent was delivered without any complications (VIDEO). Afterwards, flow of bile and liquid was observed through the lumen-apposing metal stent (LAMS). PBTHD was immediately removed. Recovery was uneventful and the patient was discharged on a normal diet with no pain on the following day. EUS-GJA via a LAMS is a well-described technique in experts’ hands (Technical review of endoscopic ultrasonography-guided gastroenterostomy in 2017. Itoi T, Baron TH, Khashab MA, et al. Dig Endosc 2017;29:495-502). Special skills and techniques are necessary in order to recognize the exact small bowel loop to puncture (Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Tyberg A, Perez-Miranda M, Sanchez-Ocaña R et al. Endosc Int Open 2016;4:E276-81). In that case, we show that filling this loop using a previous transhepatic access should be considered an alternative in case of alterated anatomy. Also direct EUS transgastric injection of contrast medium in the dilated biliary tree to fill up the jejunal stump could be considered an option to perform GJA by a single operator in a single session after safely recognizing the right loop. In addition, fluoroscopy helps to detect the exact loop puncture site. In conclusion, GJA using a LAMS is feasible, safe and useful, and transhepatic injection of liquid and contrast medium helps to adequately recognize the jejunal stump after biliopancreatic surgery.
Percutaneous nephrolithotomy
This is the case of a 60-year-old man with a large left kidney stone (>3cm) taking up the entire renal pelvis and lower calyceal cavities. Under general anesthesia, the patient is placed in a supine modified lithotomy position, with a 3L water bag underneath the left lumbar fossa to raise it. The left leg is straight whereas the right leg is put on a leg brace flexed.
A cystoscopy is performed in order to identify the left ureteral orifice and introduce a 7 French beveled ureteral stent. This stent is connected to a Foley catheter. A contrast agent is injected into the ureteral stent.
The kidney’s lower pole is punctured with an 18 Gauge hypodermic needle, making sure to stay in contact with the stone. A rigid Lunderquist® guidewire is passed into the needle. The pathway is dilated using metallic coaxial dilators and with a dilation balloon until an Amplatz® renal sheath is placed. The sheath will then be extended.
A nephroscopy is performed to identify the stone, fragment and aspirate it partially with the LithoClast Master® intracorporeal lithotripter. Some large fragments will be withdrawn with crocodile forceps. The lithotripter system fails to remove the residual stone. A Malecot®-type nephrostomy tube is used and the ureteral stent is replaced by means of a double J catheter.
C Saussine
Surgical intervention
1 year ago
2080 views
88 likes
0 comments
34:10
Percutaneous nephrolithotomy
This is the case of a 60-year-old man with a large left kidney stone (>3cm) taking up the entire renal pelvis and lower calyceal cavities. Under general anesthesia, the patient is placed in a supine modified lithotomy position, with a 3L water bag underneath the left lumbar fossa to raise it. The left leg is straight whereas the right leg is put on a leg brace flexed.
A cystoscopy is performed in order to identify the left ureteral orifice and introduce a 7 French beveled ureteral stent. This stent is connected to a Foley catheter. A contrast agent is injected into the ureteral stent.
The kidney’s lower pole is punctured with an 18 Gauge hypodermic needle, making sure to stay in contact with the stone. A rigid Lunderquist® guidewire is passed into the needle. The pathway is dilated using metallic coaxial dilators and with a dilation balloon until an Amplatz® renal sheath is placed. The sheath will then be extended.
A nephroscopy is performed to identify the stone, fragment and aspirate it partially with the LithoClast Master® intracorporeal lithotripter. Some large fragments will be withdrawn with crocodile forceps. The lithotripter system fails to remove the residual stone. A Malecot®-type nephrostomy tube is used and the ureteral stent is replaced by means of a double J catheter.