Lindström Outi, Udd Marianne, Rainio Mia, Nuutinen Hannu, Jokelainen Kalle, Kylänpää Leena
Gastroenterological Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
Gastroenterology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
Scand J Gastroenterol. 2020 Oct;55(10):1225-1233. doi: 10.1080/00365521.2020.1806351. Epub 2020 Aug 14.
Surgically altered anatomy complicates endoscopical procedures of pancreatobiliary tree. Biliary or hepaticojejunal anastomosis strictures have been managed using percutaneous transhepatic or double balloon enteroscopy (DBE) techniques with multiple plastic stents, or fully covered self-expandable metal stents. We report the first seven cases with surgically altered anatomy treated with biodegradable stents with DBE.
Seven cases with altered anatomy, all with Roux-en-Y hepaticojejunostomy (HJ), were treated for HJ anastomosis strictures (3 cases) and intrahepatic biliary stricture (4 cases). Fujifilm DB enteroscope with a 200 cm long and 3.2 mm wide working channel was used. Balloon dilatations were first performed and then 1-3 biodegradable stents were deployed with a pusher over a guidewire.
Two patients had HJ due to liver resections, one due to biliary injury in cholecystectomy and four due to liver transplantation because of primary sclerosing cholangitis (PSC). Median duration of the procedures was 56 min. Deployment of the stents took less than 20 min per patient. There were no stent or cholangiography related adverse events, but one patient required endotracheal intubation for nose bleeding caused by the placement of nasopharyngeal tube. Two PSC patients had recurrent cholangitis in the follow up. There was one stent migration in 90 day follow up. With all the HJ anastomotic strictures resolution of strictures seemed to be achieved.
Treatment of biliary or anastomosis strictures in altered anatomy is complex and time consuming. The biodegradable stent, which can be passed through working channel of a long enteroscope, seems promising in the treatment of these strictures. The benefit is that no stent removal is needed.
手术改变的解剖结构使胰胆管树的内镜操作变得复杂。胆管或肝空肠吻合口狭窄已采用经皮经肝或双气囊小肠镜（DBE）技术结合多个塑料支架或完全覆盖的自膨式金属支架进行处理。我们报告了首例使用DBE及可生物降解支架治疗的7例手术改变解剖结构的病例。
7例解剖结构改变的病例，均为 Roux-en-Y 肝空肠吻合术（HJ），分别因 HJ 吻合口狭窄（3例）和肝内胆管狭窄（4例）接受治疗。使用了工作通道长200 cm、宽3.2 mm的富士胶片DB小肠镜。首先进行球囊扩张，然后通过导丝用推送器置入1 - 3个可生物降解支架。
2例因肝切除行HJ，1例因胆囊切除术中胆管损伤行HJ，4例因原发性硬化性胆管炎（PSC）行肝移植后行HJ。手术的中位持续时间为56分钟。每位患者置入支架的时间少于20分钟。未发生与支架或胆管造影相关的不良事件，但1例患者因放置鼻咽管导致鼻出血需要气管插管。2例PSC患者在随访中出现复发性胆管炎。在90天的随访中有1例支架移位。所有HJ吻合口狭窄似乎均已解除。
治疗解剖结构改变的胆管或吻合口狭窄复杂且耗时。可通过长小肠镜工作通道置入的可生物降解支架在治疗这些狭窄方面似乎很有前景。其优点是无需取出支架。
