A 58-year-old man with chronic hepatitis B underwent right hepatectomy for a 58mm hepatocellular carcinoma. Postoperatively, persistent bilious drainage suggested a biliary leak.
ERCP revealed contrast extravasation from the proximal common bile duct (CBD) into two ill-defined collections adjacent to the surgical drain. The left intrahepatic ducts (LIHD) were not opacified, and the guidewire could only be directed toward the leak, indicating complete discontinuity. Persistent bleeding during biliary sphincterotomy prompted placement of a fully covered self-expandable metal stent (FCSEMS) for hemostasis and biliary decompression. Magnetic resonance cholangiography confirmed complete transection, showing non-dilated LIHD with no communication to the proximal CBD, which was intercepted by a perihepatic biloma.
After multidisciplinary discussion, a second ERCP with peroral cholangioscopy was proposed to guide LIHD cannulation. A 3.2mm cholangioscope (EyeMAX™) was advanced to the disrupted CBD, revealing a loculated cavity containing devitalized tissue and purulent bile. Multiple attempts to pass the guidewire into the LIHD failed, as the hepatic end of the transection was not observed. A linear echoendoscope enabled EUS-guided transgastric puncture with a 19G needle, achieving LIHD cholangiogram and anterograde cannulation. Guidewire passage into the CBD was hindered by repeated coiling within the cavity. The wire was left inside, the echoendoscope withdrawn, and the duodenoscope was reintroduced at the papilla to repeat cholangioscopy. Using a biopsy forceps through the cholangioscope, the guidewire was captured, pulled into the duodenum, and recovered to the working channel in a rendezvous procedure. A cannula was advanced into the LIHD, and the wire exchanged for retrograde access. Both transection ends were dilated with an 8mm balloon, and a 120x8mm FCSEMS was deployed, restoring biliary continuity.
The patient was discharged uneventfully a few days later. Follow-up CT showed resolution of collections, and the FCSEMS was removed after four months. Final cholangiography confirmed CBD reconstruction and complete leak resolution.
This case highlights the effectiveness of a combined EUS-ERCP-Cholangioscopy approach in managing major leaks with complete CBD transection, avoiding surgical reintervention.