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Video of Issue Successful treatment of a complete obstruction at the hepaticojejunostomy anastomosis using cholangioscopic biopsy forceps inserted via the endoscopic ultrasound-guided hepaticogastrostomy route
Sho Hasegawaorcid, Kunihiro Hosonoorcid, Masato Yonedaorcid

DOI: https://doi.org/10.5946/ce.2025.174
Published online: September 8, 2025

Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan

Correspondence: Sho Hasegawa Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan E-mail: t166064d@yokohama-cu.ac.jp
• Received: May 28, 2025   • Revised: June 10, 2025   • Accepted: June 11, 2025

© 2025 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Stricture at the site of a hepaticojejunostomy anastomosis (HJA) is a complication after pancreaticoduodenectomy. Although biliary intervention via the endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) route and endoscopic retrograde cholangiopancreatography (ERCP) with balloon-assisted enteroscopy have been reported for the management of HJA strictures,1-3 endoscopic treatment can be challenging in complete obstruction. We report a case in which combined EUS-HGS and single-balloon enteroscopy (SBE) successfully resolved a complete HJA obstruction.
A 65-year-old man underwent pancreaticoduodenectomy for intraductal papillary mucinous carcinoma 3 years earlier. During routine follow-up, liver dysfunction was detected. Magnetic resonance cholangiopancreatography revealed an HJA stricture (Fig. 1A). ERCP with SBE failed to identify the anastomosis. Therefore, EUS-HGS was performed, and a self-expandable metallic stent (SEMS; EGIS, 6 mm/10 cm; S&G Biotech) was inserted (Video 1). Cholangiography confirmed complete obstruction (Fig. 1B). After 1 month, the SEMS was removed, and a cholangioscope (SpyGlass DS; Boston Scientific) was advanced antegrade via the HGS route. Cholangioscopy revealed a membranous stricture near the HJA (Fig. 1C). Using cholangioscopic biopsy forceps, fibrotic tissue and sutures were carefully dissected and removed (Fig. 1D). Cholangiography then demonstrated restored continuity with contrast flow into the jejunum. The stricture was balloon-dilated, and a plastic stent (PS) was placed.
At the 1-month follow-up, the PS was replaced with a SEMS (Bonastent M-Intraductal, 8 mm/3 cm; Standard SciTech Inc.; Fig. 2A). One month later, endoscopic evaluation via SBE from the mucosal side confirmed fistula formation and resolution of the HJA stricture after SEMS removal (Fig. 2B).

Video 1.

Successful treatment of a complete obstruction at the hepaticojejunostomy anastomosis using cholangioscopic biopsy forceps inserted via the endoscopic ultrasound-guided hepaticogastrostomy route to remove the biliary mucosa and surrounding fibrotic tissue.
A video related to this article can be found online at https://doi.org/ce.2025.174.
Fig. 1.
(A) Magnetic resonance cholangiopancreatography showing intrahepatic bile duct dilation. The arrow indicates the complete obstruction at the hepaticojejunostomy anastomosis. (B) Cholangiography confirming complete obstruction at the hepaticojejunostomy anastomosis. (C) Cholangioscopic view revealing a membranous stricture at the anastomotic site. (D) Endoscopic removal of the biliary mucosa and surrounding fibrotic tissue using biopsy forceps (SpyBite MAX; Boston Scientific).
ce-2025-174f1.jpg
Fig. 2.
(A) Replacement of the plastic stent at the hepaticojejunostomy anastomosis with a self-expandable metallic stent. The arrow indicates the self-expandable metallic stent (Bonastent M-Intraductal, 8 mm/3 cm; Standard SciTech Inc.) (B) Mucosal-side evaluation using a single-balloon enteroscope showing resolution of the hepaticojejunostomy anastomosis stricture.
ce-2025-174f2.jpg
  • 1. Kanadani T, Ogura T, Ueno S, et al. Transluminal antegrade drill dilation technique for hepaticojejunostomy stricture with cholangioscopic evaluation (with video). Endosc Int Open 2024;12:E181–E187.ArticlePubMedPMC
  • 2. Ogura T, Nishioka N, Ueno S, et al. Gastrointestinal: guidewire insertion under transluminal cholangioscopy guidance for a hepaticojejunostomy stricture resembling a pinhole. J Gastroenterol Hepatol 2020;35:2029.ArticlePubMedPDF
  • 3. Mie T, Sasaki T, Okamoto T, et al. Risk factors for recurrent stenosis after balloon dilation for benign hepaticojejunostomy anastomotic stricture. Clin Endosc 2024;57:253–262.ArticlePubMedPMCPDF

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      Successful treatment of a complete obstruction at the hepaticojejunostomy anastomosis using cholangioscopic biopsy forceps inserted via the endoscopic ultrasound-guided hepaticogastrostomy route
      Image Image
      Fig. 1. (A) Magnetic resonance cholangiopancreatography showing intrahepatic bile duct dilation. The arrow indicates the complete obstruction at the hepaticojejunostomy anastomosis. (B) Cholangiography confirming complete obstruction at the hepaticojejunostomy anastomosis. (C) Cholangioscopic view revealing a membranous stricture at the anastomotic site. (D) Endoscopic removal of the biliary mucosa and surrounding fibrotic tissue using biopsy forceps (SpyBite MAX; Boston Scientific).
      Fig. 2. (A) Replacement of the plastic stent at the hepaticojejunostomy anastomosis with a self-expandable metallic stent. The arrow indicates the self-expandable metallic stent (Bonastent M-Intraductal, 8 mm/3 cm; Standard SciTech Inc.) (B) Mucosal-side evaluation using a single-balloon enteroscope showing resolution of the hepaticojejunostomy anastomosis stricture.

      Fig. 1.

      Fig. 2.

      Successful treatment of a complete obstruction at the hepaticojejunostomy anastomosis using cholangioscopic biopsy forceps inserted via the endoscopic ultrasound-guided hepaticogastrostomy route
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