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Endoscopic repair of complete bile duct transection by use of transpapillary cholangioperitoneoscopy

Open AccessPublished:November 06, 2017DOI:https://doi.org/10.1016/j.vgie.2017.09.007
      In this video (Video 1, available online at www.VideoGIE.org), a novel cholangioscopy-assisted approach to reconstitution of a completely transected bile duct is shown. A 24-year-old woman underwent seemingly uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis. Eighteen days postoperatively, she experienced massive ascites and bile peritonitis, which was confirmed by paracentesis. Initial ERCP showed a large leak at the proximal common bile duct with no communication to upstream ducts, which suggested a bile duct transection.
      Attempts to pass a guidewire into the proximal biliary tree were unsuccessful. EUS-guided biliary access was not possible because of the completely decompressed intrahepatic ducts. Percutaneous transhepatic cholangiography was difficult because of the small intrahepatic ducts, but access was eventually gained. Unfortunately, the biliary ductal system distal to the transection could not be visualized or accessed, and an external drain was placed.
      After multidisciplinary discussion, a temporizing approach was pursued to allow internalization of the high biliary output to allow elective management (Figs 1A-G). The percutaneous drain was advanced through the transection site into the peritoneum, and a long length of a 450-cm-long 0.025-inch guidewire was advanced into the subhepatic space. Repeated ERCP with digital cholangioscopy was performed. The proximal bile duct was found to be ulcerated at the injury site. The cholangioscope was passed outside of the bile duct at the level of the disruption into the peritoneal cavity and subhepatic space. The distal end of the percutaneous transhepatic drain and guidewire were visualized cholangioscopically. The distal portion of the wire was grasped with cholangioscopic forceps. The cholangioscope with wire was withdrawn into the duodenum. The wire was subsequently retrieved with a standard polypectomy snare and exited the endoscope.
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      Figure 1A, Gross extravasation of contrast material, which identifies a bile leak. Large amount of retained contrast material in colon from prior CT. B, Percutaneous cholangiographic view showing complete disruption of the bile duct at the level of the common hepatic duct. C, Repeated ERCP after percutaneous drain placement defines the area of transected bile duct. Notice coiled wire placed percutaneously in the subhepatic space, which will be used for rendezvous procedure. D, Magnified image showing the wire grasped by cholangioscopic forceps. E, Biliary occlusion balloon further defines the anatomy before stent placement. F, Fluoroscopic view showing a covered metal stent fully deployed over the leak site; cholangiographic view shows filling of intrahepatic biliary tree. G, Follow-up cholangiographic view after stent removal shows lack of extravasation of contrast material. Nonobstructive stricture, presumably at the site of prior bile duct injury.
      At this point access was obtained to both the percutaneous and peroral ends of the wire, with the wire traversing the defect. Repeat cholangiography allowed a 2-cm-long gap in the bile duct/common hepatic duct to be defined, confirming complete transection. An 8-mm-diameter × 10-cm-long fully covered self-expandable metal stent (SEMS) was placed in the usual retrograde fashion, leaving as much of the proximal stent below the bifurcation while still covering the leak site to preserve as much as possible of the hepatic duct for later surgery. Bilateral plastic biliary stents were placed through the SEMS. The patient’s clinical condition improved, and the bile leak resolved.
      The stents were removed 4.5 months later; cholangiography demonstrated a mild biliary stricture at the level of the transection site. A multidisciplinary decision was made to proceed with elective hepaticojejunostomy 2 months later (7 months after initial cholecystectomy) because it was believed that biliary stricture formation was inevitable. Pathologic examination of the resected bile duct showed transmural fibrosis. In conclusion, cholangioscopy-assisted rendezvous ERCP for restoration of biliary continuity is feasible for the management of complete bile duct transection as a bridge to elective, definitive surgery.

      Disclosure

      Dr Baron is a consultant and speaker for Medtronic, Boston Scientific, Cook Endoscopy, and Olympus. All other authors disclosed no financial relationships relevant to this publication.

      Supplementary data