Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports

BACKGROUND Hemorrhage associated with varices at the site of choledochojejunostomy is an unusual,difficult to treat,and often fatal manifestation of portal hypertension.So far,no treatment guidelines have been established.CASE SUMMARY We reported three patients with jejunal varices at the site of choledochojejun-ostomy managed by endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection at our institution between June 2021 and August 2023.We reviewed all patient records,clinical presentation,endoscopic findings and treatment,outcomes and follow-up.Three patients who underwent pancre-aticoduodenectomy with a Whipple anastomosis were examined using conven-tional upper gastrointestinal endoscopy for suspected hemorrhage from the afferent jejunal loop.Varices with stigmata of recent hemorrhage or active he-morrhage were observed around the choledochojejunostomy site in all three patients.Endoscopic injection of lauromacrogol/α-butyl cyanoacrylate was carried out at jejunal varices for all three patients.The bleeding ceased and patency was observed for 26 and 2 months in two patients.In one patient with multiorgan failure and internal environment disturbance,rebleeding occurred 1 month after endoscopic sclerotherapy,and despite a second endoscopic sclero-therapy,repeated episodes of bleeding and multiorgan failure resulted in eventual death.CONCLUSION We conclude that endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoac-rylate injection can be an easy,effective,safe and low-cost treatment option for jejunal varicose bleeding at the site of choledochojejunostomy.

Choledochojejunostomy with an innovative magneticcompressive anastomosis:How to determine optimalpressure?

AIM: To investigate the optimal magnetic pressure and provide a theoretical basis for choledochojejunostomy magnetic compressive anastomosis(magnamosis).METHODS: Four groups of neodymium-iron-boron magnets with different magnetic pressures of 0.1, 0.2, 0.3 and 0.4 MPa were used to complete the choledochojejunostomy magnamosis. Twenty-six young mongrel dogs were randomly divided into five groups: four groups with different magnetic pressures and 1 group with a hand-suture anastomosis. Serum bilirubin levels were measured in all groups before and 1 wk, 2 wk, 3 wk, 1 mo and 3 mo after surgery. Daily abdominal X-ray fluoroscopy was carried out postoperatively to detect the path and the excretion of the magnet. The animals were euthanized at 1 or 3 mo after the operation, the burst pressure was detected in each anastomosis, and the gross appearance and histology were compared according to the observation.RESULTS: The surgical procedures were all successfully performed in animals. However, animals of group D(magnetic pressure of 0.4 MPa) all experienced complications with bile leakage(4/4), whereas half of animals in group A(magnetic pressure of 0.1 MPa) experienced complications(3/6), 1 animal in the manual group E developed anastomotic stenosis, and animals in group B and group C(magnetic pressure of 0.2 MPa and 0.3 MPa, respectively) all healed well without complications. These results also suggested that the time required to form the stoma was inversely proportional to the magnetic pressure; however, the burst pressure of group A was smaller than those of the other groups at 1 mo(187.5 ± 17.7 vs 290 ± 10/296.7 ± 5.7/287.5 ± 3.5, P < 0.05); the remaining groups did not differ significantly. A histologic examination demonstrated obvious differences between the magnamosis groups and the hand-sewn group.CONCLUSION: We proved that the optimal range for choledochojejunostomy magnamosis is 0.2 MPa to 0.3 MPa, which will help to improve the clinical application of this technique in the future.

Gallstone in jejunal limb with jejunocolonic fistula 10 years after Roux-en-Y choledochojejunostomy

Roux-en-Y choledochojejunostomy is a common biliary reconstruction procedure.The collection of gallstones in the jejunal limb is a rare complication.Here we present a case of a 61-year-old Chinese female who received Roux-en-Y choledochojejunostomy 10 years ago.Diagnosis of recurrent bile duct stones accompanying infection was made before operation.She also had an abdominal mass which was possibly an intussuscepted colon or a huge fecolith.At laparotomy,an oval stone(5 cm in diameter) and 3 smaller multifaceted stones(2 cm in diameter) were found in the jejunal limb.A fistula between this jejunum and colon was also found.Although the typical manifestations of diarrhea were present,the diagnosis of a biliary colonic fistula was missed before operation.Partial colectomy was performed with the fistulous opening repaired.A T-tube was left in the jejunal limb and the mesocolon aperture was enlarged and revised.Her postoperative convalescence was uneventful.We report this case hoping to sharpen our diagnostic acumen.

new anastomosis method for choledochojejunostomy by the way behind antrue pyloricum

Background Reflux cholangitis has been the most common In this study we intended to evaluate the perioperative and choledochojejunostomy. complication after Roux-en-Y choledochojejunostomy. long-term efficacy of a new anastomosis method for Methods Clinical data of 143 eligible patients who underwent choledochojejunostomy in the Eastern Hepatobiliary Surgery Hospital affiliated to the Second Military Medical University, China between January 2007 and December 2010 were retrospectively analyzed. Among the patients, 38 consecutive cases underwent this new anastomosis method for choledochojejunostomy （improved group, IG） and 105 underwent standard Roux-en-Y choledochojejunostomy （control group, CG）. Changes in the incidence of cholangitis, the time of beginning to eat liquid meals, post-operative delayed gastric emptying and liver function between the two groups were compared. Results There was no statistical difference in the levels of alanine transaminase, alkaline phosphomonoesterase and gamma-glutamy transferase between the two groups. The time of beginning to eat liquid meals was significantly shorter in IG than CG （P 〈0.05）. The incidence of delayed gastric emptying was lower in IG than CG, with statistical tendency between the two groups （P=0.052）. Among nine patients with different degrees of acute cholangitis in the two groups, one patient （2.6%） in IG and eight （7.6%） in CG suffered from acute cholangitis within six months of follow-up after discharge, but with no statistical difference between the two groups （P 〉0.05）. Of the nine patients with acute cholangitis, none in IG and four in CG were hospitalized for further treatment （P 〉0.05）. Conclusions Patients in IG had satisfactory perioperative and long-term prognosis with shorter time of beginning to eat liquid meals and lower incidence of delayed gastric emptying. This new procedure of choledochojejunostomy by the way behind antrue pyloricum was easy and safe to perform with no mortality and low complication rates.

Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients

AIM: To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions. METHODS: In 37 post-surgical patients, a stepwise approach was performed to reach normal papilla or enteral anastomoses of the biliary tract/pancreas. When conventional endoscopy failed, DBE-based ERCP was performed and standard parameters for DBE, ERCP and interventions were recorded. RESULTS: Push-enteroscopy (overall, 16 procedures) reached enteral anastomoses only in six out of 37 post-surgical patients (16.2%). DBE achieved a high rate of luminal access to the biliary tract in 23 of the remaining 31 patients (74.1%) and to the pancreatic duct (three patients). Among all DBE-based ERCPs (86 procedures), 21/23 patients (91.3%) were successfully treated. Interventions included ostium incision or papillotomy in 6/23 (26%) and 7/23 patients (30.4%), respectively. Biliary endoprosthesis insertion and regular exchange was achieved in 17/23 (73.9%) and 7/23 patients (30.4%), respectively. Furthermore, bile duct stone extraction as well as ostium and papillary dilation were performed in 5/23 (21.7%) and 3/23 patients (13.0%), respectively. Complications during DBE-based procedures were bleeding (1.1%), perforation (2.3%) and pancreatitis (2.3%), and minor complications occurred in up to 19.1%. CONCLUSION: The appropriate use of DBE yields a high rate of luminal access to papilla or enteral anastomoses in more than two-thirds of post-surgical patients, allowing important successful endoscopic therapeutic interventions.

Palliative surgery for hilar cholangiocarcinoma

OBJECTIVE: To evaluate the results of palliative surgical treatment of hilar cholangiocarcinoma in terms of quality of life, survival period and cholangitis rate. MFTHODS: The clinical data on 232 patients with hilar cholangiocarcinoma in the last 22 years were analyzed retrospectively. Palliative operations included extrahepatic or intrahepatie choledochojejunostomy (123 patients), bridge internal drainage (15), endoscopic biliary drainage (49), percutaneous transhepatic biliary drainage or celiotomy biliary drainage (29), and exploratory celiotomy external drainage (16). RESULTS: In this series, the operative mortality rate was 9.1%, and no significant difference was observed between groups. The rate of cholangitis after operation was significantly lower in Roux-en-Y choledochojejunostomy group (16.2%) and bridge internal drainage group (15.4%) than in internal drainage group (35.5%, P<0.01), including percutaneous transhepatic biliary drainage (PTBD), endoscopic retrograde biliary drainage (ERBD), and celiotomy (or PTBD) external biliary drainage group (39.1%, P<0.01). No significant difference in survival was observed between the Roux-en-Y choledcthojejunostomy group (9.3±1.8 months) and PTBD (or ERBD) internal drainage group (8.7±2.2 months), but the survivals of the above groups were significantly longer than those of the bridge internal drainage group (6.5±1.7 months, P<0.05) and celiotomy (or PTBD) external biliary drainage group (4.4±2.1 months, P<0.01). CONCLUSIONS: In unresectable cholangiocarcinomas, either operative bilioenteric bypass or percutaneous transhepatic biliary drainage can achieve significant palliation. Roux-en-Y choledochojejunostomy is the best choice for palliative operation. The use of U-tube is recommended for internal radiation therapy.

Iatrogenic extrahepatic bile duct injury in 182 patients: causes and management

Objective: To describe the causes and treatment ofiatrogenic bile duct injury caused by cholecystecto-my.Methods: 182 patients with iatrogenic extrahepaticbile duct injury from 4 university hospitals of Chinawere reviewed. Details of primary cholecystectomy,biliary reconstruction as well as postoperative ma-nagement were recorded. All patients were followedup for at least 6 months (6 months to 9 years, medi-an 3.5 years). The adequacy of repair was assessedby regular evaluation of the patients clinical statusand liver function variables. Hepatobiliary B-ultra-sonography was used routinely in the follow up of pa-tients, and magnetic resonance cholangiopancreatog-raphy was applied in the patients suggestive of abnor-mality.Results: In 152 patients, bile duct injury happenedduring open cholecystectomy, and in 30 patients dur-ing laparoscopic cholecystectomy. All the injuries de-veloped during anterograde cholecystectomy (at theCalot’s triangle). All the patients with these injuriesunderwent choledochocholedochostomy or Roux-en-Ycholedochojejunostomy with good results (161 pa-tients), recurrent stricture (11), and death (10).Conclusions: During cholecystectomy, the Calot’s tri-angle should be identified anatomically, but retro-grade cholecystectomy is the optimal choice. Bileduct injury should be discovered as soon as possibleand be managed timely. Different operative methodsare optional according to the degree of injury and thepostoperative period.