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EUS-guided rendezvous technique for refractory benign biliary stricture caused by postoperative bile-duct injury

Open AccessPublished:September 30, 2017DOI:https://doi.org/10.1016/j.vgie.2017.08.006
      A 60-year-old man underwent right-sided liver lobectomy in another hospital for multiple liver metastases from an ascending colon cancer. After surgery, bile leakage and cholangitis occurred because of postoperative bile-duct injury (Fig. 1A ). A percutaneous tube and an endoscopic transpapillary drainage tube had been placed in the bile leakage cavity at the previous hospital. However, bile juice drained continuously through the percutaneous tube, and bile leakage did not improve (Fig. 1B). For further endoscopic treatment, the patient was referred to our institution. We performed an EUS-guided rendezvous technique (Video 1, available online at www.VideoGIE.org). The B3 hepatic duct was punctured transgastrically with a 22-gauge FNA needle under EUS guidance. After the puncture, a guidewire was advanced from the left hepatic duct to the bile leakage cavity. Then, the FNA needle was removed and the cannula was advanced over the guidewire. Next, the guidewire was advanced from the bile leakage cavity to the common bile duct in an antegrade fashion (Fig. 1C) and further into the duodenum through the major papilla (Fig. 1D). The echoendoscope was then removed, and the guidewire and cannula were left in place (Fig. 1E). The endoscope was advanced to the second portion of the duodenum, and the guidewire tip was grasped with a biopsy forceps (Fig. 1F) and pulled out through the working channel as the EUS-guided rendezvous technique. Finally, a 7F, 15-cm biliary stent was deployed in the left hepatic duct through the bile leakage cavity (Fig. 1G), with no adverse events. CT performed 2 months after the procedure showed healing of the bile leakage (Fig. 1H). Since then, there has been no recurrence of symptoms.
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      Figure 1A, Enhanced CT view of the abdomen showing bile leakage caused by bile duct injury. B, ERCP view showing a bile duct stricture and bile leakage. C, Advancement of guidewire from the left hepatic duct to the common bile duct in an antegrade fashion through the bile leakage cavity. D, Schematic diagram showing placement of cannula in B3 and advancement of guidewire from left hepatic duct to the ampulla in an antegrade fashion through the bile leakage cavity. E, The echoendoscope was removed and the guidewire was left in place. F, Guidewire tip grasped with a biopsy forceps. G, Deployment of 7F 15-cm plastic stent through the bile leakage cavity. H, CT view 2 months after procedure, showing healing of the bile leakage.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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