| Recurrent pancreatobiliary cancer in patients after biliary reconstruction often causes division of the left and right hepatic ducts (LHD and RHD), and drainage of both ducts is sometimes required. If a colonoscopy or balloon enteroscopy can be reached to the hepaticojejunostomy (HJ), biliary drainage can be performed from the anastomosis, but often the HJ itself cannot be seen by the tumor. In such patients, a method to bridge the LHD and RHD from EUS-guided biliary drainage from the stomach may be an alternative. However, after biliary reconstruction, the LHD and RHD are often anastomosed separately, so that this method cannot always be applied. In these patients, a direct approach to the RHD is necessary. If the RHD can be identified from the afferent limb using a forward viewing-EUS, biliary drainage can be performed. There are 3 methods available for this purpose: one is to create a fistula to place a stent between the afferent limb and RHD, the second is to place a stent over the biliary stricture which involves the HJ in an antegrade manner, and the last one is to use a rendezvous technique, in which enables the placement of multiple stents from the HJ in a retrograde manner. Using these methods, endoscopic treatment can be accomplished even in patients after biliary reconstruction. |
