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A 52-year-old woman with history of bile duct injury following cholecystectomy and previous Roux-en-Y hepaticojejunostomy was admitted because of cholangitis. Her work-up revealed a 7-mm stone in the right intrahepatic duct on magnetic resonance cholangiopancreatography (MRCP). An initial single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) revealed independent right and left hepaticojejunostomies and bilateral strictures. A large right intrahepatic filling defect was identified on an occlusion cholangiogram (▶Fig. 1). Bilateral dilation of the anastomosis was performed with an 8-mm hydrostatic balloon, but the stone could not be removed and two plastic biliary stents (7 F ×5 cm) were placed. Contrast injection into the biliopancreatic limb showed that it was closely approximated to the duodenal bulb and therefore suitable for an endoscopic ultrasound (EUS)-guided duodenojejunostomy (EUS-DJ) to facilitate access to the afferent limb and complete clearance of the bile duct using the appropriate accessories. A single-balloon enteroscope fitted with a cap was advanced to the hepaticojejunostomy. The afferent limb was filled with diluted contrast mixed with 1% methylene blue, and 2mg of glucagon was given intravenously to slow peristalsis. A linear echoendoscope was then advanced to the duodenal bulb and the distended jejunal limb was identified and punctured using a 19-gauge fineneedle aspiration (FNA) needle. Aspiration of blue-tinged fluid confirmed the correct location in the afferent limb. A cautery-enhanced lumen-apposing metal stent (LAMS; 15mm×10mm) was deployed, thereby creating a duodenojejunostomy (▶Video 1). E-Videos

endoscopy

Lumen-apposing metal stent for the creation of an endoscopic duodenojejunostomy to facilitate bile duct clearance following Roux-en-Y hepaticojejunostomy