Background

A 45-year-old woman with a history of cholelithiasis, choledocholithiasis and benign biliary stricture developed necrotizing pancreatitis with extensive intra-abdominal collections. After laparotomy for perforated cholecystitis with purulent peritonitis, she presented a vascular injury leading to hepatic ischemia and bile duct perforation secondary to a complicated cholecystectomy.

Case report

The patient underwent ERCP revealing a normal intrapancreatic bile duct with complete transection at the level of the common hepatic duct (Figure 1, Figure 2), with contrast filling of a heterogeneous subhepatic collection and spontaneous biliary drainage through the papilla (Figure 3).

Endoscopic recanalization of the intrahepatic duct or common hepatic duct was not technically achievable. Interventional radiology performed a percutaneous transhepatic cholangiography with placement of an internal–external biliary drain.

During a second ERCP, a guidewire was advanced through the percutaneous drain and retrieved endoscopically in the duodenum (“rendezvous”). A guidewire was then passed into the right hepatic duct and subsequently into the left hepatic duct. Plastic stents (9 cm × 8.5 Fr) were placed in each hepatic duct (Figure 4), and the external drain was removed.

Subsequently, both plastic stents were replaced with a fully covered self-expandable metal stent with anchoring flaps (80 × 10 mm), which was removed two months later. Follow-up cholangiography and cholangioscopy confirmed resolution of the leak and absence of biliary stricture (Figure 5).

Conclusions

Therapeutic ERCP is a fundamental tool in the management of post-surgical bile leaks.In complex scenarios such as complete bile duct transections, the combined percutaneous–endoscopic “rendezvous” technique allows restoration of biliary continuity, avoidance of major surgery, and reduction of morbidity, with technical success rates exceeding 94%. Even after failed ERCP or radiological attempts we must continue to pursue minimally invasive management options whenever possible, as demonstrated in this case.