Hepaticojejunal Anastomotic Stricture With Presentation as Biliocutaneous Fistula

Abstract

Purpose: Background: Hepaticojejunal anastomotic stricture (HAS) is a late complication of biliary diversion surgery. The most common presentation of HAS is either abdominal pain or abnormal liver enzymes. We present an unusual case of HAS presenting as a biliocutaneous fistula. Case: A 59 year old man was transferred to our facility after presenting with jaundice and drainage of bile from a papule on the right abdomen at the mid-axillary line. He had a history of chronic pancreatitis and had undergone a Whipple procedure 8 years prior. He reported 2 prior episodes of jaundice and cholangitis which had been treated with percutaneous biliary drainage two years earlier. He had no further complaints until presenting with 1 week of progressive right-sided abdominal pain, jaundice, and a raised skin lesion on his right side. This was incised by an outside provider, resulting in drainage of bile. Initial bilirubin level was 9.0 mg/dL. He was admitted, and imaging with computed tomography revealed a fluid-filled sinus tract extending from the skin to the dome of the liver. Following transfer he underwent single balloon enteroscopy with endoscopic retrograde cholangiogram (ERC). A stenotic hepaticojejunal anastomosis was encountered, and cholangiogram revealed diffusely dilated intrahepatic ducts. Following cannulation and balloon dilation of the stricture to 8mm, multiple stones were swept from the biliary tree and two 7 French biliary stents were placed. The patient's bilirubin failed to improve and 2 days later the procedure was repeated with dilation to 9 mm and placement of two 8.5 French stents. He experienced no further drainage from the fistula site. At the time of his follow-up ERC 3 months later, his total bilirubin level had decreased to 1.6 mg/dL. The anastomosis had partially restenosed. The biliary stents were removed, followed by endoscopic sphincteroplasty and further dilation of the anastomosis. The patient has had no recurrent symptoms over the past 7 months of follow-up. Conclusions: This case illustrates the unusual presentation of HAS with spontaneous biliary decompression via a biliocutaneous fistula. The fistula followed the course of a previously closed percutaneous biliary drain tract. The case also demonstrates the therapeutic capability of ERC via single balloon enteroscopy in treating HAS via dilation and endoscopic stricturoplasty.