Percutaneous transhepatic cholangioscopy with cholangiography-guided choledochojejunostomy: a bridge drainage technique for distal common bile duct stenosis after Begerʼs operation

A 48-year-old woman who had undergone Beger's operation for a serous cystic adenoma of the pancreatic head 5 months previously, suffered recurrent fever and jaundice for 3 months. Abdominal computed tomography and two failed attempts at endoscopic retrograde cholangiopancreatography (ERCP) indicated a distal common bile duct (CBD) stenosis ([Fig. 1]). The bridge drainage technique applied between two non-communicating anatomic structures is potentially a promising biliary drainage strategy for malignant or benign biliary obstruction [1] [2] [3]. Given the Roux-en-Y limb of pancreaticojejunostomy was adjacent to the CBD after the Begerʼs operation and to minimize duodenal biliary reflux, we report for the first time a novel bridge drainage approach between the CBD and the adjoining Roux-en-Y limb using percutaneous transhepatic cholangioscopy, instead of recanalization of the CBD stenosis ([Video 1]).

Fig. 1 Images from two endoscopic retrograde cholangiopancreatographies that failed: a owing to the duodenal stenosis; b with biliary cannulation proving impossible.

Bridging of the common bile duct (CBD) and the adjoining Roux-en-Y limb using ultrasound-guided percutaneous transhepatic cholangioscopy is successfully performed to treat a distal CBD stenosis after Begerʼs operation.Video 1

The operation started with ultrasound-guided one-step puncture of the CBD. A guidewire was inserted, facilitating the use of dilators until an 18-Fr sheath could be placed. Multiple attempts to pass the guidewire through the CBD stenosis were unsuccessful ([Fig. 2]). In situ puncture towards the left and ventral side in the established sheath was then performed under ultrasound guidance to link the CBD with the Roux-en-Y limb. The puncture channel was further expanded by a ballon, with good flow of contrast medium from the CBD into the bowel ([Fig. 3]). Finally, an 18-Fr biliary drainage catheter was placed for support and drainage, with a 10-Fr pigtail catheter placed inside to prevent distal displacement ([Fig. 4] a).

Fig. 2 Direct cholangioscopic visualization and intraoperative cholangiography showing: a severe distal common bile duct (CBD) stenosis, with a completely obstructed CBD (yellow dashed square); b a failed attempt to pass the guidewire through the CBD stenosis; c no passage of contrast medium into the bowel system on cholangiography.

Fig. 3 Successful creation of the connection between the common bile duct (CBD) and the adjoining Roux-en-Y limb showing: a the biliary ballon placed through the puncture approach and repeatedly inflated to a pressure of 10 bar for 2 minutes to dilate the channel; b the successfully dilated puncture channel; c the flow of contrast medium from the CBD into the bowel system on cholangiography.

Fig. 4 Postoperative appearance: a initially, with an 18-Fr biliary drainage catheter positioned in the common bile duct (CBD) for support and drainage, and a 10-Fr pigtail catheter inside the catheter to prevent distal displacement; b 4 weeks later, a covered self-expanding metal stent placed through the drainage catheter to achieve internal drainage under percutaneous fluoroscopic guidance.

After 4 weeks, during which there were no postoperative complications, a covered self-expanding metal stent was placed under percutaneous cholangiography guidance as a replacement for the drainage catheter to bridge the CBD and the adjoining Roux-en-Y limb, thereby achieving completely internal drainage ([Fig. 4] b). Ultrasound-guided percutaneous transhepatic cholangioscopy combined with cholangiography for bridging of the CBD and the adjoining Roux-en-Y limb, while minimizing duodenal biliary reflux, may provide a safe and feasible treatment option for such CBD stenosis after failed ERCP.

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Artikel online veröffentlicht:
10. April 2025

• References

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