36 - Image-guided Percutaneous Creation of Pexied Roux Limb of Jejunum (Hutson Loop) for Biliary Interventions

Purpose: Evaluate the feasibility, safety, and utility of image-guided percutaneous creation of pexied Roux limb of jejunum (Hutson loop) by interventional radiologists for subsequent percutaneous transjejunal biliary interventions performed under fluoroscopic and endoscopic guidance.

Materials and Methods: Three patients at one academic medical center underwent image-guided percutaneous Hutson loop creation. These patients had prior Roux-en-Y hepaticojejunostomies and required long-term ( > 6 months) percutaneous transhepatic biliary drainage for biliary strictures. The procedure involved using endoscopic and fluoroscopic guidance to advance 3 pexy T-fasteners into the lumen of the Roux limb to anchor the loop of small bowel to the anterior abdominal wall. The site was localized for subsequent interventions by placing two 2 mm x 2 cm S coils into the abdominal wall musculature under ultrasound and fluoroscopic guidance. Patients were monitored with clinical follow-up for immediate and long-term complications.

Results: Pre-procedural CT following biliary drain placement demonstrated the Roux limb apposed to the anterior abdominal wall in all cases. The modified Hutson loop was created successfully in all cases. The patients tolerated the Hutson loop creation procedure well with no immediate or long-term complications. One patient underwent technically successful cholangiogram, cholangioscopy, and biliary drain removal via the Hutson loop 6 weeks after creation. Percutaneous biliary drains were removed in all cases, with the modified Hutson loop available for future biliary interventions if needed.

Conclusion: Fluoroscopic and endoscopic guided creation of a Hutson loop with pexy T-fasteners in the Roux limb of a hepaticojejunostomy is feasible in patients where the Roux limb approximates the anterior abdominal wall. This procedure can be done safely and provides retrograde transjejunal access for a variety of biliary interventions without the subsequent need for biliary drains.