Journal Article

Grab Both Ends and Pull: Stenting the Unstentable Bile Duct Injury Using EUS Rendezvous

Samarasena, Jason, Lee, John, Jalali, Farid, Abadir, Alexander P

2018

Overview

Most post-cholecystectomy biliary strictures can be treated endoscopically as long as stenting is possible. We describe a successful EUS-guided antegrade approach to treatment of a benign post-cholecystectomy stricture, which could not be stented conventionally due to an acute angle alpha loop deformity of the bile duct. A 70 year-old woman with history of laparoscopic cholecystectomy one year ago presented to another hospital with biliary obstruction and cholangitis. She reported a complicated course after surgery with percutaneous drainage of a biliary leak for months. Cholangiogram showed a biliary stricture at the level of hilum and a plastic biliary stent was placed in what was thought to be the right intrahepatic duct. However, she continued to have recurrent biliary obstruction. EUS showed dilated intrahepatics with smooth tapering of the bile duct distally without a mass or a transition point. FNA of perihepatic lymph nodes were negative for malignancy.She was transferred to our institution after recurrent cholangitis. ERCP showed the existing stent to terminate in a tubular structure in the direction of the right intrahepatic duct. Cholangiogram showed faint filling of what looked like a short right hepatic duct beyond the surgical clips as previously described. However occlusion cholangiogram demonstrated an extremely tight and acutely angulated stricture away from the originally seen duct which turned out to be the old percutaneous drainage tract. Although we were able to pass a guidewire to the intrahepatic duct, exhaustive efforts at passing any catheter failed as it impacted in the false tract and flipped the wire out. EUS-guided antegrade approach was performed for biliary stenting. We punctured the left intrahepatic duct under EUS and manipulated a guidewire antegrade to the distal bile duct, again creating an alpha loop within the false tract as with prior attempt during ERCP. The echoendoscope was exchanged for the duodenoscope and the guidewire was secured at the EUS puncture site and at the ampulla and gently pulled to 'straighten out' the bile duct. Retrograde balloon dilation and stenting of the stricture was then performed without difficulty. Repeat ERCP with stent exchange two months later showed healing of the false tract and a patent stricture. This case demonstrates that securing the guidewire at both ends greatly facilities stenting and is helpful in patients with difficult anatomy.

• Publisher: Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins
• Subject: Bile ducts / Cholangitis / Cholecystectomy / Gastroenterology