Byers, J, Percutaneous Cholangioscope-Assisted Laser Incision of Hepaticojejunostomy Stenosis and Obstruction

UCCOM Research Symposium 2022 Abstract

Category: Clinical Surgery

Subcategory: Interventional Radiology

Percutaneous Cholangioscope-Assisted Laser Incision of Hepaticojejunostomy Stenosis and Obstruction

Jacob Byers, UCCOM M21 ; Ali Kord, MD, MPH, Interventional Radiology (PI)2

1University of Cincinnati College of Medicine; 2Division of Interventional Radiology, Department of Radiology, University of Cincinnati College of Medicine

Introduction: Patients who undergo Roux-en-Y hepaticojejunostomy (HJ) may have post procedure complications such as HJ anastomotic strictures (HJS). These HJS can occur in up to 38% of cases, and often require additional imaging and procedures to repair. The current methods employed to repair HJS often result in recurrence, necessitating additional interventions.

Conventionally, patients with HJS undergo a percutaneous trans-hepatic cholangiography (PTC) with a percutaneous trans-hepatic biliary drain placement (PTBD). Patients are then followed as part of benign biliary stricture protocol every 2-3 weeks for regular PTC, and gradual cholangioplasty upsizing. This protocol lasts for 5-6 months before the catheter can be removed, often significantly impacting the patients’ quality of life.

Percutaneous cholangioscope-assisted laser incision (CALI) is a novel intervention, that utilizes a percutaneous cholangioscope (SpyGlass-Discovery, Boston Scientific). The cholangioscope can be deployed percutaneously to directly visualize the stenosis. A laser can be introduced through the cholangioscope to incise the HJS, followed by cholangioplasty and biliary drain placement. This study is designed to investigate the efficacy and complications of CALI in patients with HJS.

Methods: All patients underwent CALI of HJS at UCMC were included in this study. The dates of their initial HJ procedure, first biliary drain, size of cholangioplasty, drain size, drain removal date were recorded. Time with a biliary drain prior to CALI and time to drain removal post procedure was reported.

The previous catheter was exchanged over a guide wire for a 14 French percutaneous transhepatic sheath. PTC was performed to localize the stenosis. A cholangioscope was advanced to the stenosis, and laser incision was performed. The laser specifications were: 365 um bare Holmium fiber laser with an output of 1.0 J/pulse at a rate of 10 Hz. Cholangioplasty was performed and a capped safety drain was placed.

Results: A total of 5 patients (3 male, 2 female; median age: 49 years old) with benign HJS were included in the study. Four of the patients had chronic biliary drains for 5-72 months (median: 28.5) with histories of drain upsizing and cholangioplasties. One patient had a drain for one month prior to undergoing CALI. There was a technical success rate of 100%. Four of the patients had the drain removed within a month post procedure, three of them within 16 days. One patient required an additional round of CALI and drain upsizing, with final drain removal at 2 months post CALI. There were no major complications or incidence of reoccurrence during the follow period (median 277 days).

Conclusion: This study demonstrated the feasibility of CALI in the treatment of HJS in a small number of patients. Based upon the initial results of this study, further investigation is warranted to explore the efficacy of CALI on HJS.

Contact: Jacob Byers, ByersJB@mail.uc.edu

Key Words: Cholangioscope, Interventional Radiology, hepaticojejunostomy, stricture, laser