Sp707 Endoscopic Recanalization Technique for Complete Ligation of Bile Duct after Cholecystectomy

Abstract

Bile Duct Injury after cholecystectomy remains a major problem in current surgical practice. BDI is associated with poor survival, increased morbidity and impaired quality of life. The current standard practice for management of BDI is the following: Amsterdam Type A and B lesions (cystic and bile duct leak) should be treated with sphincterotomy and placement of stent; Type C lesions (strictures) should be treated by endoscopy (failures should be considered for surgery); Type D lesions (transection or ligation of the bile duct) should be treated by surgery. In this presentation, we will, for the first time, demonstrate an endoscopic method of biliary recanalization in three patients with complete ligation of the common bile duct. We will present three cases of patients that had undergone cholecystectomy and presented, after 2 to 4 weeks, clinical evidence of jaundice. By a three-step ERCP procedure, we accessed the common bile duct and passed a specialized needle through the complete stenosis. It was used a specialized needle catheter that presented some characteristics, such as an 18-gauge needle, internal channel that fitted a .35-inch guidewire, and a distal tip covered by a flexible metallic sheath with 10 cm length. At this first moment, we used a .35-inch guidewire to maintain proximal bile duct access and performed plastic stent (first case) or self-expandable metallic stent placement. In the first patient, it was a three step procedure that consisted in 8.5 Fr plastic stent placement, followed by balloon dilation of the stenosis with multi-stent placement, and finalized by the multi-stent removal. In the second and third cases, instead of a plastic stent, a self-expandable metallic stent was used. This alternative reduced the treatment to two steps and it was not necessary to perform a balloon dilation of the stenosis. A clinical resolution of the stenosis was observed in the three patients, with a mild narrowing of CBD in radioscopic images. It is important to know that, before performing this procedure, all patients had undergone a colangioresonance, which demonstrated that cranial and distal biliary stumps were aligned. Endoscopic recanalization of CBD was an effective technique and avoided surgery in patients with Type D bile duct injury. We hypothesize that patients whose MRCP demonstrate just CBD ligation are more likely to have a successful outcome, while those with complete transection should be referred to surgical evaluation, however we present a case series demonstrating feasibility of endoscopic recanalization by using a specialized needle catheter.