The use of double balloon enteroscopy for diagnosis and treatment of strictures of hepaticojejunal anastomoses after primary correction of bile duct injuries

Abstract

Introduction: Development of strictures of hepaticojejunal anastomoses (HJA) is observed in 6-30% of patients and mortality after repeated reconstructive interventions ranges from 13% to 25%. Double balloon enteroscopy (DBE) allows one to visualize the zone of Roux-en-Y anastomosis after reconstructive operations on the bile ducts for differentiation between stricture of HJA and recurrent cholangitis. Aim: Report on the first experience of DBE of jejunal loop studies after reconstructive operations on the biliary tract. Material and methods: During the period 2002-2012 we performed in our centre 86 hepaticojejunostomies after iatrogenic bile duct injuries. Mean age was 51 ± 6 years. Patients with Roux-en-Y HJA and jejunum loop with Braun's bypass anastomosis who underwent DBE with endoscopic retrograde cholangiography (DBE-RChG) in our unit between February 2009 and December 2012 were enrolled in this study. A total of 33 procedures were performed during this period. All of them involved examination of HJA through a jejunum loop by DBE with capture of bile for bacteriology, Roux loop wall for biopsy and miniinvasive procedures. Results: The DBE-RChG after visualization of the HJA zone was performed in 21 cases: 3 of them had the jejunum loop to Braun's bypass, 18 - HJA on the Roux loop. In 13 cases stricture of HJA was confirmed: at 6 reoperations were performed, in 7 - miniinvasive procedures (3 - laser vaporizations, 2 - stone extraction, 1 - lithotripsy, 1 - at the first stage stone extraction was carried out, then laser vaporization). The DBE-RChG was performed in 13 (61.9%) patients. The overall diagnostic success with Braun's bypass was 100%, after Roux-en-Y reconstruction in 10 of 13 cases (55.6%). In connection with accumulation of experience, in 2012 diagnostic success in DBE-RChG of HJA on Roux loop increased to 81.3%. Conclusions: The MRI-ChG in our series frequently (10.3%) shows a false-positive result in favor of HJA strictures. The DBE examination of HJA with additional cholangiography is a modern and precise method of detection of HJA strictures. Their DBE-balloon dilation and argon-laser vaporization or DBE lithoextraction are new ways of miniinvasive treatment.