Double-balloon endoscopy-assisted treatment of hepaticojejunostomy anastomotic strictures and predictive factors for treatment success

Background: Endoscopic management of hepaticojejunostomy anastomotic strictures is technically demanding due to surgically altered anatomy. The promise of double-balloon endoscope-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) has been reported in this setting. No large study has examined long-term outcomes of this new treatment modality and predictive factors for the stricture resolution. Methods: We included 102 patients who received DB-ERCP for a hepaticojejunostomy anastomotic stricture between 2008 and 2018. Balloon dilation was performed as a first-line treatment, and plastic stent(s) were placed for refractory cases. Potential predictive factors for the stricture resolution were examined using multivariable logistic regression analyses. Results: DB-ERCP was technically successful in 91 patients (89.2%). Overall, stricture resolution was achieved in 70 patients (76.9%) with a median follow-up period of 30.9 months (range 1–118.5 months). Among 64 patients (71.9%) who underwent successful re-canalization via balloon dilation, anastomotic stricture recurred in 22 patients (34.4%). In cases with refractory or recurrent stricture after balloon dilation, 20 patients (52.6%) underwent stricture resolution via plastic stent placement, and the recurrence was observed in two patients (10%). Post-operative time to DB-ERCP of > 12 months and the scar-like appearance around the anastomosis were associated with a higher rate of stricture resolution (odds ratios, 5.59 [95% CI 1.69–18.5] and 5.22 [95% CI 1.29–21.1], respectively). Conclusions: Treatment of hepaticojejunostomy anastomotic strictures via DB-ERCP was technically feasible, providing a reasonably high rate of stricture resolution. Alternative treatment should be explored for refractory cases.