Melissa S Phillips, MD, Jeffrey M Marks, MD, Amitabh Chak, MD. University Hospitals, Case Medical Center, Cleveland, OH, USA
Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) can be quite challenging in patients without native anatomy. Being able to apply this “standard of care” treatment to a surgically altered patient group offers advantages of decreased morbidity and quicker recovery as compared to surgical interventions such as a common bile duct exploration or biliary bypass.
Patient: This patient is a 79 year old female status post esophagectomy with cervical esophagostomy for iatrogenic perforation. Additionally, she underwent partial gastrectomy with Billroth II reconstruction for complications of peptic ulcer disease, and feeding tube jejunostomy, which is her primary source for nutrition. She then presented with cholangitis from an impacted common duct stone. She was treated emergently with a transhepatic internalized drainage catheter. After a discussion of continued lifelong internal/external drainage, surgical intervention, or endoscopic therapy, she opted for attempted endoscopic treatment.
Treatment: A small caliber, forward viewing endoscope was introduced in the proximal direction through the jejunostomy site. The gastrojejunostomy was identified and the afferent limb was followed to the major papilla. A wire was passed through the transhepatic catheter, grasped by the endoscope and removed in rendezvous technique through the jejunostomy. A side viewing duodenoscope was then introduced over the wire with eventual cannulation of the common bile duct. Stones were removed using a combination of endoscopic sphincterotomy, sphincter dilation, and balloon extraction. Several days post-procedure, a CT scan showed a perihepatic abscess with jejunal pneumatosis, managed with percutaneous drainage, bowel rest, and antibiotics. The patient subsequently recovered with relief of her biliary obstruction, and without any additional sequela.
Conclusions: Surgically altered anatomy may present challenges in performing ERCP. This technique of a retrograde small bowel approach through a jejunostomy tube site, assisted by transhepatic rendezvous, offers a novel approach in this patient with complex anatomy, avoiding a major surgical intervention.
Program Number: V012