Extra-anatomical intraduodenal endoscopic–radiologic biliary rendezvous for treatment of iatrogenic complete stenosis of the common bile duct

 

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Minimally invasive radiologic–endoscopic recanalization or reconstruction of the common bile duct (CBD) for benign complete stenosis or complex iatrogenic lesions is routinely practiced at some tertiary centers [1] [2]. Various techniques have been reported, including endoscopic ultrasound (EUS)-guided insertion of a magnet through a previous choledochoduodenostomy [1] [2] [3] [4].

A 38-year-old woman who had undergone laparoscopic cholecystectomy 6 months earlier developed an iatrogenic biliary fistula with partial stenosis of the CBD. A biliary fully covered self-expanding metallic stent (FCSEMS) was placed for 2 months, but jaundice and pain recurred 3 months after its removal. Occlusive endoscopic retrograde cholangiography revealed complete stenosis at the mid CBD ([Fig. 1]).

A guidewire was maneuvered to perforate the CBD at a point distal to the stricture, and percutaneous transhepatic cholangiographic guidance was used to perforate the hepatic duct with a guidewire at a point proximal to the stricture ([Fig. 2]). However both guidewires tended to advance in the direction of the duodenal bulb, and several attempts to achieve a rendezvous in the subhepatic space failed. Therefore, we then advanced both guidewires along the preferential route to reach the duodenal bulb through the same hole, created by the guidewire ([Fig. 3 a]), thus avoiding significant duodenal injury. Next, with a Dormia basket that had been inserted endoscopically, the proximal guidewire was grasped ([Fig. 3 a], [Fig. 3 b]) and constant, controlled traction was applied to extra-anatomically establish continuity of the biliary tree ([Fig. 4 a], [Fig. 4 b], [Fig. 4 c]). An FCSEMS (Wallflex; Boston Scientific, Natick, Massachusetts, USA) was delivered for definitive treatment and scheduled to be replaced after 6 months ([Fig. 5]). The patient was discharged from the hospital the next day on a normal diet.

Endoscopic–radiologic reconstruction of an injured bile duct is a feasible and safe technique that spares the patient the major surgery of bilioenteric reconstruction. We report here the first case of extra-anatomical (i. e., intraduodenal) rendezvous to re-establish biliary continuity in a patient with an iatrogenic complete stricture. This report should encourage the use of other alternative methods, such as “pure EUS-guided endoscopic biliary rendezvous,” that make it possible to avoid the step of subhepatic rendezvous, which has been problematic until now.

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• References

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