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ACG Case Rep J
ACG Case Rep J
ACGCRJ
AC9
ACG Case Reports Journal
2326-3253
Wolters Kluwer Maryland, MD

ACGCR-24-0474
10.14309/crj.0000000000001480
00009
3
Case Report
Biliary
Needle Knife Stricturoplasty for Hepaticojejunostomy Stricture After Whipple Procedure
Mirminachi Seyedbabak MD 1mirminachis@upmc.edu

Slivka Adam MD, PhD 2slivkaa@upmc.edu

Mahmood Sultan MD 2
1 Department of Internal Medicine, University of Pittsburgh Medical Center, Harrisburg, PA
2 Department of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA
Correspondence: Sultan Mahmood, MD (mahmoods7@upmc.edu).
9 2024
05 9 2024
11 9 e0148018 5 2024
17 7 2024
24 7 2024
© 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

ABSTRACT

Hepaticojejunostomy anastomotic stricture is a relatively uncommon postoperative complication after a Whipple procedure. However, they are increasingly being observed because of advancements in operative mortality rates and the widening of operative indications to include benign diseases such as chronic pancreatitis and intraductal papillary mucinous neoplasm. In this article, we describe a patient diagnosed with intraductal papillary mucinous neoplasm and another with pancreatic cancer, both of whom developed jaundice after undergoing the Whipple procedure. Subsequent investigation revealed a benign hepaticojejunostomy anastomotic stricture, successfully treated with stricturoplasty using a needle knife.

KEYWORDS:

Whipple
stricturoplasty
needle knife
OPEN-ACCESSTRUE
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pmcINTRODUCTION

Biliary enteric anastomotic strictures represent notable complications in patients who undergo Roux-en-Y hepaticojejunostomy or choledochojejunostomy after pancreaticoduodenectomy, liver transplantation, or biliary tract surgeries for the repair of bile duct injuries or bile duct resection. These strictures occur as postoperative complications in 10% of patients who undergo surgical repairs of bile duct injuries and in 2.5%–13% of liver transplant recipients.1–4 In addition, they are reported as relatively rare complications occurring in 3%–7% of patients 2–4 years after the Whipple procedure.5,6 These postoperative complications are becoming more common as operative mortality rates improve and surgical indications expand to benign conditions such as chronic pancreatitis and intraductal papillary mucinous neoplasm. Anastomotic stricturoplasty poses a challenge after the Whipple procedure because of altered anatomy. Consequently, hepaticojejunostomy anastomotic strictures (HJAS) were mainly managed with percutaneous or surgical interventions, which are invasive and associated with adverse events.7 However, less-invasive techniques such as balloon dilation and stent placement using endoscopic retrograde cholangiopancreaticography (ERCP) are currently the main therapeutic modalities for hepaticojejunostomy (HJ) strictures after gastrointestinal reconstruction.8,9 In this article, we describe 2 cases of obstructive jaundice 2 months after the Whipple procedure, found to be due to HJAS, which were extremely tight and required needle knife excision to facilitate access and stenting.

CASE REPORT

Case 1

The 52-year-old man, with no significant medical history, presented with abdominal pain and diarrhea. A computed tomography scan of the abdomen and pelvis (CTAP) revealed pancreatic atrophy and ductal dilation, whereas a magnetic resonance imaging showed dilatation of the main pancreatic duct because of a cystic mass. Endoscopic ultrasound demonstrated a fish mouth ampulla with extruding mucus and a dilated main pancreatic duct extending from the ampulla, measuring up to 14 mm in diameter in the pancreatic head. These findings were confirmed by pancreatic protocol computed tomography scan. Elevated levels of carcinoembryonic antigen at 280 ng/mL, along with KRAS and GNAS mutations, were detected in the fluid aspirated from the ampulla.

The patient subsequently underwent robotic-assisted classic pancreaticoduodenectomy and cholecystectomy. He tolerated the surgery well and was discharged on pancreatic enzymes. Pathology report showed mixed main and branch duct intraductal papillary mucinous neoplasm with intermediate-grade dysplasia but no evidence of invasive adenocarcinoma, with negative surgical margins.

Two months after the surgery, the patient presented with dark urine, jaundice, and light-colored diarrhea. Blood work showed transaminitis with hyperbilirubinemia (total bilirubin 7.8 mg/dL and direct bilirubin 5.5 mg/dL). Computed tomography imaging indicated mild intrahepatic and extrahepatic biliary ductal dilation, consistent with stenosis at the HJ anastomosis. Endoscopic retrograde ERCP was performed using a pediatric colonoscope. The afferent limb was identified, and the scope was advanced to the HJ and pancreaticojejunostomy. Pancreaticojejunostomy was found to be open with a normal pancreatic duct, while HJ revealed a very tight benign-appearing stricture (Figure 1). The wires measuring 0.035″ and 0.025″ were unable to traverse, leaving us only able to pass the Nova Gold wire, which measures 0.018″ in size. However, attempts to pass the 9-12 extraction balloon (Extractor Pro XL; Boston Scientific, Marlborough, MA), dilatation catheter, and balloon dilator (Hurricane RX; Boston Scientific) were unsuccessful. A Boston Scientific needle knife, measuring 2 mm, was used to perform a free-hand stricturoplasty with 3 incisions (Figures 1 and 2). The bile duct was then cannulated deeply after guiding the 9- to 12-millimeter balloon (Extractor Pro XL; Boston Scientific) over the guidewire. After this, the HJ stricture underwent successful balloon dilation using a 4-mm balloon dilator (Hurricane RX; Boston Scientific) and a covered metal biliary stent 10 mm × 4 cm (Viabil stent; Gore, Flagstaff, AZ) placed in the common bile duct (Figure 1). After procedure, the patient's jaundice spontaneously resolved, and he was discharged the next day. Two months later, an ERCP was performed to remove the biliary stent. Remarkably, the stricture had completely resolved without any signs of recurrence (Figure 1). The biliary tree was swept, and no abnormalities were found.

Figure 1. (A) The hepaticojejunostomy (HJ) stricture; (B) HJ stricture after needle knife stricturoplasty; (C) covered metal biliary stent placed; (D) 2 months after HJ stricturoplasty.

Figure 2. Schematic illustration of needle knife stricturoplasty technique. Three separate incisions were made to dissect the scar tissue.

Case 2

The second case is a 46-year-old woman who presented with elevated liver enzymes, intense generalized itching, and mild jaundice 5 months after undergoing a Whipple procedure and cholecystectomy for moderately differentiated ductal adenocarcinoma in the head of the pancreas. Her liver enzymes continued to rise with a cholestatic pattern despite discontinuing FOLFIRINOX as per her oncologist's recommendation. A CTAP with contrast revealed new-onset biliary dilation.

The patient underwent ERCP using pediatric colonoscope, which revealed a pinhole HJAS in the afferent jejunal limb, along with upstream biliary dilation (Figure 3). A straight 0.021-inch Tracer Metro Direct wire was passed into the left intrahepatic duct. A 4-5-7 push dilator (Soehendra biliary dilation catheter; Cook Medical, Bloomington, IN) would not traverse the tight HJ anastomosis. Subsequently, free-hand needle knife technique was used to widen the stenosis, followed by successful dilation of the HJ anastomosis with a 6-mm balloon dilator (Figure 3). She continued her adjuvant chemotherapy regimen and had an uneventful postoperative course, remaining free of further complications related to HJ anastomosis.

Figure 3. (A) Hepaticojejunostomy pinpoint anastomosis; (B, C) stricture after needle knife stricturoplasty (arrows).

Three years later, she presented again with abdominal pain and jaundice, accompanied by elevated liver enzymes. A CTAP with contrast showed intrahepatic ductal dilatation. ERCP revealed recurrence of a pinhole HJAS in the afferent jejunal limb along with multiple filling defect consistent with stones in the right and left hepatic ducts. Successful dilation was achieved using an 8- to 10-mm controlled radial expansion dilator.

DISCUSSION

In this article, we present 2 cases of benign severe HJAS that developed shortly after the Whipple procedure. Attempts to access across the stricture with catheters were unsuccessful, prompting the utilization of needle knife stricturoplasty.

Enteroscopy-assisted ERCP with needle knife stricturoplasty of the HJ after the Whipple procedure has been previously reported in one case.10 This technique can serve as a rescue method to facilitate access to the biliary tract, enabling decompression in patients with altered surgical anatomy who developed biliary-enteric anastomotic strictures.

DISCLOSURES

Author contributions: S. Mirminachi: study concept and design, acquisition of data, and drafting of the manuscript. A. Slivka and S. Mahmood: study concept and design; critical revision of the manuscript for important intellectual content. S. Mahmood is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.
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