Endoscopy after radiology: Two-step combined therapy for biliary stricture after Roux-en-Y hepaticojejunostomy

Benign postoperative anastomotic strictures after hepaticojejunostomy are difficult to manage. Before interventional techniques were developed, surgical intervention was the only option for treatment. A 28-year-old man underwent Whipple procedure with Roux-en-Y hepaticojejunostomy for abdominal trauma. Two years later, a late anastomotic biliary stricture was diagnosed. A percutaneous cholangiography showed a severe stricture in the hepaticojejunostomy. Because of the severity and length of the stricture, and the failure of repeated percutaneous balloon-dilations, we percutaneously placed a self-expandable metal stent, a nitinol polytetrafluoroethylene fully covered flared-type stent, 3 cm in length, with 10 mm of diameter. The patient was soon discharged home in good general condition that remained stable in the 6 months of follow up. To remove the biliary stent, we carried out single-balloon enteroscopy. The stent was captured with a standard polypectomy snare. To avoid injury to the mucosa, the stent was removed through the overtube, which remained in situ. Cholangiogram showed a normal biliary tree, with resolution of the anastomotic stenosis. The patient remained stable throughout the 8 months of follow up, and required no further biliary procedures. In cases of failure of standard procedures, this new two-step, combined percutaneous and endoscopic approach can be useful and feasible, avoiding surgery-related morbidity and mortality. However, the fact that these procedures should be carried out only by highly experienced endoscopists and interventional radiologists familiar with these specialized procedures cannot be overstressed.