Bile duct injuries can occur at various sites, and the Strasberg classification is useful in considering their treatment strategy [1 ]. A Strasberg Type B injury is a bile duct obstruction that commonly occurs from the atypical right hepatic duct, and its endoscopic treatment is difficult [2 ].
A 70-year-old man who underwent pancreaticoduodenectomy for ampullary carcinoma was referred to our department because of abdominal pain and fever. Computed tomography and magnetic resonance cholangiopancreatography showed a fluid collection on the liver surface and dilation of the right anterior hepatic duct, resulting in a diagnosis of cholangitis and bile leakage ([Fig. 1 ]). Although a double-balloon endoscope-assisted endoscopic retrograde cholangiopancreatography (ERCP) was performed, the right anterior hepatic duct could not be identified ([Fig. 2 ]). Percutaneous transhepatic biliary drainage (PTBD) was performed, resulting in symptomatic improvement ([Fig. 3 ]). A review of the preoperative images revealed a variation in the right anterior bile duct, which was ligated during surgery, resulting in complete occlusion
Fig. 1 Computed tomography and magnetic resonance cholangiopancreatography showed a fluid collection on the liver surface and dilation of the right anterior hepatic duct (arrows).
Fig. 2 Although a double-balloon endoscope-assisted endoscopic retrograde cholangiopancreatography was performed, the right anterior hepatic duct could not be identified.
Fig. 3 Percutaneous transhepatic biliary drainage was performed for the right anterior hepatic duct.
For the internal drainage, we attempted an endoscopic ultrasound (EUS)-guided hepaticojejunostomy. A forward-viewing echoendoscope (TGF-UC260J; Olympus, Tokyo, Japan) was inserted along a nasobiliary drainage tube placed in the left hepatic duct ([Video 1 ]). After bile duct puncture with a fine-needle aspiration (FNA) needle, a guidewire was placed into B8 and the puncture site was dilated with a drill dilator (Tornus ES; Asahi Intec, Aichi, Japan). An additional guidewire was then placed into B5 using a double-lumen catheter (PIOLAX, Tokyo, Japan). The puncture site was dilated with a balloon catheter, followed by placement of a 7-Fr plastic stent and an 8-mm-diameter fully covered metal stent (M-Intraductal; Medico’s Hirata Inc., Osaka, Japan) ([Fig. 4 ]). The PTBD catheter was removed and the patient was discharged two days postoperatively. Hepaticojejunostomy using a forward-viewing echoendoscope is a promising treatment option for a complete obstruction associated with a postoperative bile duct injury.
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Endoscopic ultrasound-guided hepaticojejunostomy was performed using a forward-viewing echoendoscope. The dilated right anterior branch was punctured with a fine-needle aspiration needle, followed by dilation of the puncture site and stent placement.Video 1
Fig. 4 A 7-Fr plastic stent and an 8-mm-diameter fully covered metal stent were placed in a side-by-side fashion.
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