An Impassable Artificial Intestinal Valve During Double-balloon Enteroscopy for Recurrent Cholangitis 18 Years After Choledochal Cyst Excision

Congenital biliary dilatation (formerly referred to as choledochal cyst) is a congenital anomaly characterized by cystic dilatation of the bile ducts. Historically, an artificial intestinal valve (AIV) was sometimes added to Roux-en-Y reconstruction to prevent postoperative reflux cholangitis, but its clinical significance remains controversial. We report the case of an 18-year-old man who underwent excision of congenital biliary dilatation and Roux-en-Y hepaticojejunostomy with an AIV during infancy. He developed recurrent cholangitis from 16 years of age. Magnetic resonance cholangiopancreatography showed mild intrahepatic bile duct dilatation and a microabscess in segment 5. Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography was performed for biliary evaluation. However, the endoscope could not pass through the severely narrowed orifice of the AIV, which meant that reaching the hepaticojejunostomy was impossible. His symptoms improved with conservative antibiotic treatment, and no further cholangitis has occurred. He subsequently transitioned to the adult Gastroenterology Department and undergoes annual imaging follow-up. While AIVs are introduced to prevent reflux, recent studies have suggested that postoperative cholangitis is multifactorial. In this case, the AIV became a critical obstacle to endoscopic access approximately 20 years postoperatively.With advancements in double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography, securing future endoscopic access is increasingly important.An AIV can hinder endoscopic biliary access after congenital biliary dilatation surgery, and our institution has since discontinued its use.