10 years of EUS-guided enteral-enteral endoscopic bypass (EEEB) and subsequent ERC to treat hepatico-jejunostomy's anastomotic stricture

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Aims Since re-do surgery and interventional radiology are considered the first-line treatment for bilio-digestive anastomotic stricture, endoscopic treatment has been used as a minimally invasive alternative for the management of these adverse event considering both EUS-guided and retrograde approaches. We proposed a totally endoscopic approach to improve the endotherapy of bilio-digestive anastomotic stricture [ 1 ] [ 2 ]. Methods From January 2014 to December 2023, 87 consecutive patients affected by bilio-digestive anastomotic stricture treated by endoscopic enteral-enteral bypass (EEEB) and subsequent endoscopic retrograde cholangiography (ERC) were included in the present study. 77 patients underwent hepaticojejunostomy on Roux-en-Y loop; 10 patients underwent Whipple-Child procedure. Results 87 consecutive patients (mean age=66 y.o.; 53 M, 34 F) underwent EEEB which was successful in all but two patients because of a perforation secondary to bypass stent misplacement during the stent’s release and an intraprocedural bleeding (technical success rate in 85/87, 97.5%). When EEEB was successfully performed in all the cases with the effective treatment of the anastomotic biliary stricture using large bore fully-covered self-expandable metal stents (SEMS). During a mean follow-up of 66 months (range: 12-120 months), we reported a 100% clinical success (defined as clinical complete resolution of the stricture). In seven cases, recurrent biliary stricture occurred, successfully re-treated through the EEEB (biliary strictures’ recurrence rate: 8.2%). Five cases of buried flair of the lumen-apposing metal stent used for the EEEB into the gastric wall were reported; four treated by pneumatic dilation and stent-in-stent treatment and one by redo EEEB. No other long-term adverse events were experienced. Conclusions EEEB-guided ERC is safe, feasible, and effective in tertiary referral centers with high-level experience in both ERCP and EUS. It lets the use of endoscopes with large operative channel to treat the stenosis(es) with large-bore SEMS to manage complex and multiple-ducts biliary anastomosis’ strictures, to guarantee a long-lasting gradual dilation and to re-treat the patients in case of recurrence [ 3 ]. Publication History Article published online: 27 March 2025 © 2025. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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