Hepatic lesions are common in abdominal traumas [1] and generally involve liver parenchyma.
Nevertheless, bile duct lesions are rare and challenging to treat [2]
[3].
Biliodigestive anastomoses are the most frequently performed surgeries [3], but the risk of long-term adverse events is high, especially for biliary anastomotic
strictures [4].
Here we present a case of traumatic biliary disconnection previously treated by biliodigestive
latero-lateral anastomosis on Roux-en-Y-loop, complicated by anastomotic stricture.
A 42-year-old man without relevant comorbidities was unseated from his horse and reported
a severe bile leak due to intrapancreatic biliary tract disconnection. For this reason,
he underwent hepaticojejunal latero-lateral anastomosis on Roux-en-Y-loop, with previous
ligation of the distal choledocus.
After six months, a biliary anastomotic stricture developed and percutaneous transhepatic
biliary drainage was performed as the primary treatment.
Because of the very low quality of life due to poor tolerance/compliance with percutaneous
transhepatic biliary drainage, the patient was referred to our endoscopy center.
At first, a standard approach to the major duodenal papilla was attempted with a duodenoscope
(ED-127; Pentax Medical), but it failed because the intrapancreatic biliary tract
was completely disconnected.
At this point, an occlusive cholangiography was performed (using a Fogarty balloon
pushed into the bile duct through the percutaneous access) ([Fig. 1]) in order to make the common bile duct visible on endoscopic ultrasound. The Hot
AXIOS electrocautery-enhanced delivery system (Boston Scientific) was chosen to change
the approach, and a fully covered, 8 × 8-mm lumen-apposing metal stent (LAMS) was
released between the duodenum and the choledocal stump ([Fig. 2]). Then a fully covered, 16-mm × 2-cm biflanged metal stent (Nagi Stent; EuroMedical
Corp.) was placed through the hepaticojejunostomy using the percutaneous access to
achieve stable dilation of the anastomotic stricture ([Fig. 3]).
Fig. 1 Occlusive percutaneous cholangiography using a 12-mm Fogarty balloon to dilate the
common bile duct and make it visible under endoscopic ultrasound.
Fig. 2 To safely open the lumen-apposing metal stent in a small-caliber common bile duct,
the stent was placed as deep as possible in the biliary tract through a guidewire.
Fig. 3 Biflanged stent and lumen-apposing metal stent at 1-month follow-up.
At the six-month follow-up, both stents were removed, and two “hand-tailored,” fully
covered, 6-mm × 3-cm self-expandable metal stents (WallFlex; Boston Scientific) were
placed through the new choledocoduodenostomy to consolidate the anastomosis ([Video 1]). The stents were positioned crosswise in order to avoid excessive tightening on
the walls of the biliary ducts ([Fig. 4]).
Video 1 A case of traumatic choledochal disconnection previously treated by biliodigestive
latero-lateral anastomosis on Roux-en-Y-loop complicated by anastomotic stricture
and solved by “tailored” endoscopic treatment.
Fig. 4 “Hand-tailored,” fully covered, self-expandable metal stents placed through the choledochoduodenostomy
crosswise to avoid excessive tension of the anastomotic area.
These stents were removed after six months and, at the cholangiography, the choledocoduodenostomy
was patent ([Fig. 5]). The patient remained asymptomatic and no recurrence of symptoms was reported.
Fig. 5 Final oucome on the hepaticojejunostomy.
Endoscopy_UCTN_Code_TTT_1AR_2AG
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
