Duckbill-type antireflux self-expandable metal stent placement for post-choledochojejunostomy reflux cholangitis

Abstract

Reflux cholangitis is a common complication of choledochojejunostomy [1] [2]. Intestinal content reflux is considered a possible cause for this complication when there is no stenosis at the choledochojejunal anastomosis [3] [4] [5], and post-choledochojejunostomy reflex cholangitis (PCRC) is not an indication for endoscopic procedures (e. g., stenting). Here, we discuss using antireflux self-expandable metal stents (ARMS) to treat a patient with PCRC. A 43-year-old woman who 4.5 years earlier had undergone total pancreatectomy and choledochojejunostomy (Child reconstruction) for multiple pancreatic neuroendocrine tumors presented with fever caused by PCRC. She was treated with antibiotics and ursodeoxycholic acid. However, the fever recurred two or three times a week. Computed tomography showed pneumobilia, and ^99 mTc-N-pyridoxyl-5-methyltryptophan (^99 mTc-PMT) hepatobiliary scintigraphy showed high tracer uptake in the afferent and blind loops. Endoscopy (CF-H260AI; Olympus Medical Systems, Tokyo, Japan) revealed that the choledochojejunal anastomosis was dilated with cholestasis. No bile duct stones were observed ([Fig. 1]). We speculated that PCRC was caused by cholestasis in the anastomosis and planned for ARMS placement. Cholangiography showed that the common hepatic duct was 23 mm in diameter; side-by-side placement of two 10-mm ARMS was considered ideal. A 7-Fr plastic stent (Harmo Ray; Hanaco Medical, Saitama, Japan) was inserted into B6 to prevent the posterior branch from being obstructed by the ARMS. Two duckbill-type ARMS (D-ARMS; 10 mm × 6 cm; Kawasumi Laboratories, Tokyo, Japan; [Fig. 2]) were placed in the anterior branch and the left hepatic duct, respectively, using the side-by-side method. To prevent stent migration, the D-ARMS were fixed to the jejunal mucosa using clips (SureClip; Micro-Tech Endoscopy, Ann Arbor, Michigan, USA) ([Fig. 3], [Fig. 4]; [Video 1]). Video 1 D-ARMS placement in a patient with refractory post-choledochojejunostomy reflux cholangitis. Hepatobiliary scintigraphy showed that cholestasis was notably reduced in the afferent and blind loops after the procedure, and the patient’s fever had improved ([Fig. 5]). This is the first report discussing D-ARMS placement in PCRC. Dramatic improvement of symptoms was observed, demonstrating that D-ARMS can serve as a new treatment for PCRC. Endoscopy_UCTN_Code_TTT_1AS_2AD Publication Date: 20 August 2020 (online) © Georg Thieme Verlag KG Stuttgart · New York