ID: 3527114 COMBINED ENDOSCOPIC/PERCUTANEOUS RENDEZVOUS FOR BILIARY CONTINUITY… CERB THE LEAK WHEN TRADITIONAL METHODS FAIL

Abstract

CBD transection or partial resection is a severe iatrogenic injury that requires surgical reconstruction and exploration. Herein, we have reported a novel combined PTC and endoscopic rendezvous technique to achieve biliary continuity in these patients. A 65-year-old female presented with abdominal pain to an outside facility a few days after elective cholecystectomy performed for symptomatic cholelithiasis. She was found to have elevated troponin levels consistent with a non-ST elevation myocardial infarction and a CT scan showed free peritoneal fluid concerning for bile leak. She was transferred to our facility for higher level of care. A HIDA scan confirmed the bile leak. An ERCP was performed with successful cannulation of the CBD, revealing a stricture in the CBD at the site of surgical clip with free upstream contrast extravasation and no communication to proximal ducts suggesting CBD disruption/resection. The case was discussed at our weekly pancreatico-biliary multispecialty conference, and due to high surgical risk resulting from her myocardial infarction and extensive regional wall motion abnormalities on transthoracic echocardiogram, a rendezvous procedure was planned after literature review of a similar case previously reported. A percutaneous trans-hepatic cholangiogram showed no passage of contrast to the CBD; a guidewire was advanced through the right intrahepatic ducts across the bifurcation. A simultaneous ERCP was performed with CBD cannulation and spy glass examination. A miniature forceps was used to grasp the guidewire proximal to the common bile duct and pulled through the scope to achieve continuous access of the patient’s intrahepatic and extrahepatic biliary tree. A covered metal stent was placed over the guidewire through the endoscope and deployed from the intrahepatic biliary tree through the extrahepatic biliary tree and into the duodenum with visible drainage of bile. A retrograde cholangiogram revealed biliary continuity with adequate opacification of the left and right biliary tree with no contrast extravasation. The patient tolerated the procedure well, with resolution of abdominal pain and neutrophilia. A follow up CT scan revealed marked improvement in the abdominal fluid collection. A combined PTC and endoscopic rendezvous technique can successfully achieve biliary continuity in patients with iatrogenic transection or partial resection of bile duct when traditional endoscopic methods fail for patients who are less than ideal candidates for surgical exploration.