Endoscopic ultrasound-guided hepaticojejunostomy using forward-viewing echoendoscope for hepatic duct obstruction due to postoperative bile duct injury

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.

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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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995; 180: 101-125
• 2 Mercado MA, Domínguez I. Classification and management of bile duct injuries. World J Gastrointest Surg 2011; 3: 43-48

Publication History

Article published online:
12 March 2025