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A novel endoscopic technique using fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy: the saddle-cross technique (with video)

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Abstract

Background

In recent years, the number of patients with hepaticojejunostomy anastomotic strictures has increased. Balloon dilation and placement of multiple plastic stents have proven effective for hepaticojejunostomy anastomotic strictures. However, for refractory strictures, there is often a need for repeated endoscopic procedures within a short period. This study aimed to assess the efficacy and safety of the new saddle-cross technique, which uses two fully covered self-expandable metallic stents.

Methods

This was a retrospective analysis of 20 patients with benign hepaticojejunostomy anastomotic strictures who underwent placement of two fully covered self-expandable metallic stents at the National Cancer Center, Japan, from November 2017 to June 2021.

Results

The technical and clinical success rates were 100% (20/20). The median time of the procedure was 61 (range 25–122) min. The scheduled stent removal rate was 70% (14/20). Spontaneous dislodgement of the stent was observed on computed tomography in five patients (25.0%). The non-restenosis rate 12 months after the saddle-cross technique was 88.2% (15/17). Procedure-related early adverse events included mild ascending cholangitis in three patients (15.0%) and sepsis in one patient (5.0%). Procedure-related late adverse events included mild ascending cholangitis in three patients (15.0%) and bile duct hyperplasia in one patient (5.0%).

Conclusions

The saddle-cross technique performed using two fully covered self-expandable metallic stents resulted in promising long-term stricture resolution with a high technical success rate. Based on these findings, the saddle-cross method can be considered an option for the standard procedure for benign hepaticojejunostomy anastomotic strictures.

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Funding

This work was supported in part by The National Cancer Center Research and Development Fund (31-A-13).

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Authors and Affiliations

  1. Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan

    Yuki Kawasaki, Susumu Hijioka, Yosikuni Nagashio, Akihiro Ohba, Yuta Maruki, Kosuke Maehara, Motohiro Yoshinari, Yuya Hisada, Shota Harai, Hidetoshi Kitamura, Yumi Murashima, Takehiko Koga, Shun Kawahara, Syunsuke Kondo, Chigusa Morizane, Hideki Ueno & Takuji Okusaka

  2. Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan

    Yuki Kawasaki, Jun Ushio & Kiichi Tamada

  3. Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan

    Shunsuke Sugawara, Miyuki Sone & Yasuaki Arai

  4. Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan

    Takeshi Takamoto, Satoshi Nara, Daisuke Ban, Minoru Esaki & Kazuaki Shimada

  5. Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan

    Yutaka Saito

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  1. Yuki Kawasaki
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Correspondence to Susumu Hijioka.

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Disclosures

Drs. Yuki Kawasaki, Susumu Hijioka, Yosikuni Nagashio, Akihiro Ohba, Yuta Maruki, Kosuke Maehara, Motohiro Yoshinari, Yuya Hisada, Shota Harai, Hidetoshi Kitamura, Yumi Murashima, Takehiko Koga, Shun Kawahara, Syunsuke Kondo, Chigusa Morizane, Hideki Ueno, Jun Ushio, Kiichi Tamada, Shunsuke Sugawara, Miyuki Sone, Takeshi Takamoto, Satoshi Nara, Daisuke Ban, Minoru Esaki, Yasuaki Arai, Kazuaki Shimada, Yutaka Saito, and Takuji Okusaka have no conflicts of interest or financial ties to disclose.

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Supplementary file1 (MP4 172260 kb)—Video 1 Saddle-cross technique procedure explained through radiographic and endoscopic imaging. Pretreatment computed tomography showed bile duct dilation from hepaticojejunostomy anastomosis. First, we reached the hepaticojejunostomy anastomosis and evaluated the level of the benign stenosis, in this case it is moderate. Cannulation was done. On cholangiography, the left and right bile duct were delineated clearly. Next, we dilated the stricture using an 8-mm balloon catheter. Two guidewires were safely placed in the left and right anterior hepatic ducts. Subsequently, two fully covered self-expandable metallic stents were placed into the ducts, making a saddle-cross like shape. After 1-month, abdominal X-ray showed two fully covered self-expandable metallic stents remaining. The long lasso attached to the fully covered self-expandable metallic stent was caught using rat-tooth retrieval forceps and the stents were removed one by one. After the stent removal, stricture resolution and adequate dilation were evaluated by cholangiography and endoscopic images. Post-treatment computed tomography showed pneumobilia. Here, we can see the difference of anastomotic site before and after treatment.

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Kawasaki, Y., Hijioka, S., Nagashio, Y. et al. A novel endoscopic technique using fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy: the saddle-cross technique (with video). Surg Endosc 36, 9001–9010 (2022). https://doi.org/10.1007/s00464-022-09358-9

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  • DOI: https://doi.org/10.1007/s00464-022-09358-9

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