EUS-guided biliary drainage in a patient after postcholecystectomy complete biliary transection (with video).

Abstract

Biliary injury occurs after cholecystectomy in 0.3%–2.7% of patients.[1] Minor injuries can be managed endoscopically, whereas major injuries generally require surgical reconstruction.[2] However, due to the development of EUS-guided biliary drainage (EUS-BD) techniques, endoscopic minimally invasive treatment may be applied even for major injuries. Here, we describe a case of postcholecystectomy complete biliary transection managed endoscopically using the EUS-BD technique. An 85-year-old man was referred to our hospital for the treatment of severe cholecystitis. He was a bedridden patient with a history of liver cirrhosis and normal-pressure hydrocephalus. We performed subtotal cholecystectomy instead of total cholecystectomy due to severe adhesions and intraoperative bleeding. After the surgery, continuous biliary leakage occurred. Computed tomography showed a small amount of perihepatic ascites. The hilar bile duct was obscured, but the intrahepatic bile ducts were not dilated [Figure 1a and b]. We attempted endoscopic biliary stenting via ERCP to relieve the biliary pressure. However, we abandoned this approach because cholangiography revealed common bile duct disruption [Figure 2]. Magnetic resonance cholangiopancreatography also revealed complete transection of the common bile duct [Figure 3]. We decided to try endoscopic biliary stenting via EUS-BD because we considered that reoperation for this patient might lead to a poor result [Video 1]. The transected hilar duct was punctured from the duodenum because the B2 and B3 branches were not dilated. Cholangiography showed biliary leakage from the B6 branch. A plastic stent (TYPE-IT stent; Gadelius Medical Co., Ltd., Tokyo, Japan) was placed from the hilar bile duct to the duodenum. No procedure-related complications occurred, and biliary leakage was resolved.Figure 1: Computed tomography showing a small amount of perihepatic ascites. The hilar bile duct is obscured (arrow). The intrahepatic bile ducts are not dilated. (a) Axial view. (b) Coronal viewFigure 2: Cholangiography showing common bile duct disruptionFigure 3: Magnetic resonance cholangiopancreatography showings complete transection of the common bile duct (arrows)Surgical reconstruction for biliary injury was associated with a high morbidity rate of 20%–31%.[2] Endoscopic biliary stenting via EUS-BD can serve as a minimally invasive treatment option for patients with poor general conditions. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.