EUSランデブー法により治療したBillroth-II法再建術後閉塞性黄疸の1例 SUCCESSFUL ENDOSCOPIC ULTRASOUND-GUIDED RENDEZVOUS TECHNIQUE FOR A CASE OF MALIGNANT LOWER BILE DUCT OBSTRUCTION FOLLOWING BILLROTH II RECONSTRUCTION

症例は86歳，男性．2カ月前に十二指腸癌からの腫瘍出血に対し，姑息的胃空腸バイパス術（Billroth-II法再建）が施行された．皮膚黄染，心窩部痛にて当科を受診し，画像検査から十二指腸癌浸潤による胆管閉塞が疑われた．細径大腸内視鏡を用いてERCPを試みたが胆管挿管できず，内視鏡の乳頭到達は比較的容易であったことよりEUSランデブー法による胆道ドレナージを行った．EUSガイド下に拡張した肝内胆管を経胃的に穿刺し，狭窄部を超えてガイドワイヤーを十二指腸内に留置し，細径大腸内視鏡を挿入し経乳頭的にプラスチックステントを留置し減黄し得た．本法は術後再建腸管における胆管挿管困難例で乳頭到達可能な場合の閉塞性黄疸の治療選択肢として有用と思われた．

An 86-year-old male was admitted to our hospital for evaluation of obstructive jaundice and upper abdominal pain. Two months earlier, he had undergone palliative Billroth II gastroenterostomy for bleeding due to duodenal cancer. Computed tomography demonstrated a dilated bile duct and lower bile duct stricture due to probable duodenal cancer invasion. Therefore, endoscopic retrograde cholangiopancreatography (ERCP) was attempted using a long pediatric colonoscope (PCF-240L). Although we could endoscopically reach the papilla of Vater, repeated attempts to cannulate the bile duct were unsuccessful. Endoscopic ultrasonography (EUS) demonstrated a dilated intrahepatic bile duct in the left lobe (B2) ; therefore, an EUS-guided rendezvous technique was performed. We punctured the dilated bile duct (B2) via the transgastric approach under EUS guidance using a 19-gauge FNA needle, and a long 0.035-inch guidewire was advanced across the lower bile duct stricture and papilla into the duodenum. The echoendoscope was then removed and a long pediatric colonoscope (PCF-240L) was inserted. The transpapillary guidewire was retrieved with a grasping forceps, biliary cannulation was successfully performed, and a plastic stent was deployed. There were no procedure-related complications and the serum bilirubin level decreased to the normal range. In the context of failed conventional ERCP, the EUS-guided rendezvous technique appears to be an effective alternative method of biliary drainage in patients with surgically altered gastrointestinal anatomy and an endoscopically accessible papilla.