The proximal common bile duct was accidentally removed during laparoscopic cholecystectomy
in a 43-year-old man. Biliary drainage was successfully re-established in our clinic
by the formation of a jejunal interponat, but the patient’s cholestasis relapsed,
due to delayed biliary drainage and moderate stenosis of both jejunal anastomoses
(Figure [1] a). Attempts to manage this by crossing of the interponat to the opposite opening with
a guide-wire during endoscopic retrograde cholangiography or percutaneous trans-hepatic
cholangiography failed.
A rendezvous maneuver was then performed. First, a guide-wire was advanced into the
interponat via percutaneous trans-hepatic cholangiography, where it was grasped with
a Dormia basket and was used to guide an 8.5-Fr pushing catheter (PC 8.5; Wilson-Cook,
Winston-Salem, North Carolina, USA) through the endoscope to the proximal anastomosis.
A second guide-wire was then inserted through this catheter into the left intrahepatic
bile duct (Figure [1] b). With two guide-wires in place, an 8.5-Fr, 15-cm endoprosthesis was advanced, after
dilation, into each hepatic lobe. Finally, a third transpapillary, 8.5-Fr, 9-cm endoprosthesis
was placed into the jejunal interponat (Figure [1] c). The patient’s cholestasis resolved and 6 months later no significant strictures
were detected, and all the endoprostheses were removed. The patient has been asymptomatic
for 4 years.
Figure 1 Modified rendezvous technique for bilateral biliary drainage in a patient with a jejunal
interponat of the common bile duct and anastomotic strictures. a Percutaneous trans-hepatic cholangiography showing the jejunal interponat with moderate
stenosis of the hepato-jejunal anastomosis (black arrow) and of the jejuno-biliary
anastomosis (white arrow). b The percutaneously introduced wire (white arrow) has been grasped with a Dormia basket
in the jejunal interponat and pulled through the endoscope. Using an 8.5-Fr pushing
catheter placed over the first wire through the endoscope, a second wire (black arrow)
was placed in the left intrahepatic bile duct. c The final result, showing two 8.5-Fr, 15-cm endoprostheses, one in the left intrahepatic
bile duct and one in the right intrahepatic bile duct, and an 8.5-Fr, 9-cm endoprosthesis
in the jejunal interponat.
In this case, a rendezvous maneuver [1] was combined with a double-wire technique using a pushing catheter for the insertion
of a second guide-wire through a biliary jejunal interponat into the left lobe of
the liver. Bilateral hepatic drainage was thus ensured without the need for a second
percutaneous puncture, and dilation of the strictures with placement of endoprostheses
resulted in sustained remission of the patient’s cholestasis, even after removal of
the stents.
Endoscopy_UCTN_Code_TTT_1AR_2AJ
