1407 Foreign Body Erosion into the Biliary Tree—How to Avoid a Hepaticojejunostomy

Abstract

INTRODUCTION: Cholecystectomy remains one of the most common surgical procedures in the United States with a rate of greater than 750,000 annually. Of these cases, approximately 1-2% are complicated by a bile leak. Although the rate of bile leaks is relatively low, the morbidity and mortality can be very high with patients rapidly deteriorating after presentation usually due to sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) can detect greater than 95% of leaks and provide therapeutic intervention aimed at eliminating the pressure gradient across the Sphincter of Oddi which promotes the flow of bile into the duodenum to heal the injured portion of the biliary tree. This case aims to show the significant clinical benefit of endoscopic management of bile leaks, although with the novel use of direct cholangioscopy. CASE DESCRIPTION/METHODS: This is a case of a 45-year-old woman with no significant past medical history who presented to an outside hospital with cholecystitis and underwent open cholecystectomy. Surgery was complicated by duodenal injury which was primary repaired and a Jackson-Pratt (JP) drain was left in place. Bilious fluid returned from the JP drain on post-operative day two and she underwent an ERCP which confirmed a bile leak and a sphincterotomy was performed and a stent was placed. She was referred to our center for stent removal four months later and at the time her cholangiogram was negative for leak so a stent was not replaced (Figure 1). Within a week of the procedure she had bilious return from the JP drain and a tube study preformed via the JP drain was read as a “normal T-tube” cholangiogram (Figure 2). As there was suspected erosion of the JP drain into the biliary tree and high concern for creating a biliary injury when removing the drain, direct cholangioscopy was used for safe removal and identification of the leak (Figure 3). The biliary injury was sealed with a fully covered self-expanding metal stent with excellent results and no further evidence of ongoing leak. DISCUSSION: ERCP remains the preferred treatment option for bile leaks and prevents patients from having to undergo corrective operation.4 In this case there was high concern for creating a biliary injury when removing the drain, thereby direct cholangioscopy was used for safe removal and identification of the leak. To our knowledge this is the first report of JP drain erosion into the CBD with use of direct cholangioscopy and ERCP as endoscopic management for removal and treatment of biliary injury.