Direct needle puncture technique using a radial miniature probe for complete anastomotic obstruction after hepaticojejunostomy

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Abstract
Anastomotic stenosis of the hepaticojejunostomy is a major complication following pancreaticoduodenectomy [1]. In cases of complete anastomotic obstruction, drainage has been attempted using a cholangioscope via the percutaneous transhepatic biliary drainage route or a forward-viewing echoendoscope [2] [3]. However, reports of direct puncture of the anastomotic site remain scarce [4]. Here, we present a case of complete hepaticojejunostomy obstruction successfully managed with direct needle puncture drainage using a radial miniature probe (UM-2R; Olympus, Tokyo, Japan). A 72-year-old woman was under postoperative surveillance following surgery for pancreatic tail cancer when an iatrogenic recurrence of pancreatic head cancer was detected. She subsequently underwent residual pancreatectomy. Postoperatively, she developed obstructive jaundice ([Fig. 1] and [Fig. 2]) and was referred to our department. Single-balloon enteroscopy (SIF-H290S; Olympus, Tokyo, Japan) was performed to evaluate the hepaticojejunostomy anastomosis; however, complete occlusion precluded biliary drainage. The endoscope was then switched to a therapeutic video gastroscope (GIF-H290T; Olympus, Tokyo, Japan) to access the anastomotic site. Water was slowly injected through the auxiliary water channel, and the water-filled area surrounding the hepaticojejunostomy was visualized using the UM-2R. The right hepatic artery and portal vein were clearly identified, confirming a safe trajectory for puncturing the anastomosis and accessing the bile duct. A 19-G needle was used to directly puncture the hepaticojejunostomy anastomosis, allowing successful cholangiography. Following guidewire placement, the anastomotic stenosis was dilated with a biliary balloon catheter, and 7-Fr biliary stents were placed in the right and left hepatic ducts, achieving effective drainage ([Video 1]). Direct needle puncture of the hepaticojejunostomy anastomosis carries potential risks, including small intestinal perforation, bile leakage, and vascular injury leading to hemorrhage. However, the use of the UM-2R enabled safe bile duct access and drainage while mitigating complications, thus broadening the scope of endoscopic management for anastomotic stenosis. Endoscopy_UCTN_Code_TTT_1AS_2AH Article published online: 12 March 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany