Minimally invasive treatment of intrahepatic cholangiolithiasis after stricture of hepaticojejunal anastomosis

Introduction

Benign strictures of hepaticojejunal anastomoses (HJA) are observed in 10–30% of cases after reconstructive operations on the bile ducts [1, 2]. However, from 62.3% to 75% of such patients are reported to be subjected to repeated operations for recurrent anastomotic strictures [3, 4].
Quite often this pathology may be complicated by recurrent cholangitis, cholangiolithiasis, hepatic failure and liver cirrhosis [5, 6]. According to Negi et al., liver cirrhosis resulting from biliary obstruction can develop within 3.8–14.8 months of the postoperative period [7].
Traditionally, repeated reconstructive surgery for strictures of HJA and cholangiolithiasis is associated with traumatic interventions decreasing the quality of patients’ lives and increasing the risk of their developing recurrent stricture formation [8]. According to Bismuth, in 60–90% of cases each subsequent operation leads to stricture level type IV–V [9, 10].

Case report

On December 12, 2016 a 70-year-old woman was admitted to our center with complaints of abdominal pain, jaundice, and fever. Previously, in 2014, she had been subjected to a pancreatoduodenal resection for ductal adenocarcinoma. Since February 2016 she had had clinical manifestations of cholangitis: periodic abdominal pain, temperature up to 38°C, and icteric skin. According to the data obtained through the magnetic resonance cholangiography in October 6, 2016, the patient’s intrahepatic ducts were enlarged. She had a common hepatic duct (CHD) length of 21 mm with an oval-shaped intraluminal filling defect of 21 × 9 mm, while the distal common bile duct was not visualized (Photo 1).
In December 22, 2016 the patient was subjected to a combined minimally invasive treatment with simultaneous double-balloon enteroscopy (DBE) of the Roux-en-Y loop under the guidance of percutaneous transhepatic cholangiography (PTCG). The procedure was as follows.
The right intrahepatic bile duct was punctured in the right 7th intercostal space in the mid-axillary line. The cholangiography revealed a filling defect in the lobar hepatic ducts, confluence and CHD (20 × 15 mm). The contrast agent was instilled into the small bowel through the stenotic HJA (Photo 2).
We performed the recanalization of the HJA using a conductor and a catheter. A 10 Fr introducer was inserted into the lumen of the bile ducts, through which the lumen became accessible by a cholangioscope. A dense concrement obturating the duct lumen and the zone of anastomosis was visualized in the area of the confluence and the HJA (Photo 3 A). This manipulation allowed for laser lithotripsy of the concrement (wavelength of 1440 nm, power of 12 W) (Photo 3 B).
The lithotripsy through the conductor was followed by balloon dilatation of the HJA with subsequent transportation of the stones below the anastomosis into the jejunum (Photo 4).
After the double-balloon-enteroscope (DBE) was retrieved to the anastomosis zone, the concrement obturating the lumen was removed with a Dormia basket inserted through the working channel of the DBE (Photo 5).

Discussion

Recently, there has been observed a tendency to frequently use minimally invasive methods for the diagnosis and treatment of cholangiolithiasis and strictures of HJA: percutaneous transhepatic biliary drainage, PTCG with balloon dilatation of the anastomosis, lithotripsy with lithoextraction using DBE, and stenting [11–13]. According to Mueller et al., the efficacy of percutaneous transhepatic interventions for strictures of HJA ranges from 67% to 73% [14]. However, when used separately, these methods are not always effective. There are also technical difficulties in performing DBE in case of surgically altered anatomy of the small bowel.
In the period from 2002 to 2016 we treated 58 patients with strictures of HJA after previous reconstructive operations on the bile ducts. Thirteen (22.4%) patients developed intrahepatic cholangiolithiasis within 1 to 3 years of the postoperative period. Minimally invasive operations were performed on 12 (20.7%) patients, and repeated reconstructive operations on 46 (79.3%) patients (Table I).
Undoubtedly, present day medical advances and patients’ needs spur and facilitate new approaches to treatment. Thus, we have developed and implemented a rare and innovative “rendezvous” technique (percutaneous transhepatic lithotripsy and antegrade balloon dilatation of stricture of HJA with simultaneous retrograde DBE) that can be applied to patients with surgically altered anatomy of the jejunum.
The suggested treatment-diagnostic algorithm allows one not only to identify the stricture and intrahepatic concrements, but also to prevent stone formation using minimally invasive antegrade and retrograde interventions to restore the patient’s biliary drainage (Figure 1).

Conclusions

The methods of corrective treatment of strictures of HJA combined with cholangiolithiasis as a follow-up to reconstructive operations on the bile ducts are a priority tool for elderly patients with a concomitant pathology. Nowadays, the combination of antegrade balloon recanalization or laser vaporization of stricture of HJA with retrograde DBE and extraction of concrement fragments is recognized as a new, efficacious and safe treatment of cholangiolithiasis and strictures of HJA.

Conflict of interest

The authors declare no conflict of interest.

References

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Received: 26.07.2017, accepted: 2.10.2017.