Stage hepaticogastrostomy and retroperitoneoscopy to reconnect a transected bile duct. These are our disclosures. A 32-year-old female experienced a high output bile leakage on postoperative day one after laparoscopic cholecystectomy. She underwent emergent laparotomy, a Jackson Pratt drain was placed, and a subsequent ERCP, massive contrast extravasation into a biloma with lack of intra-hepatic bile duct filling, was noted. A stage endoscopic treatment approach was offered to the patient involving EOS-guided hepaticogastrostomy with a fully covered self-expandable metal stand to provide internal biliary drainage and allow elective antegrade guidewire access into the biloma. Then ERCP with cholangioscopy and retroperitoneoscopy for retrograde access into the biloma and guidewire retrieval, allowing plastic stand insertion across the transected bile duct and transpapillary double pigtail drainage of the biloma. Then, as an outpatient procedures, plastic stand across the transection was upgraded to a fully covered self-expandable metal stand together with removal of the double pigtail and hepaticogastrostomy stands. And a second revision, a fully covered metal stand was exchanged at the ERCP to consolidate bile duct repair. So, even if standard management of transected bile ducts involves surgical hepaticogenostomy, on occasion, combined ERCP and interventional EOS may offer a minimally invasive alternative for complete repair in selected patients by a sequence of hepaticogastrostomy initially to allow internal biliary drainage and elective guidewire access upstream the transection. Then, transpapillary retroperitoneoscopy to facilitate guidewire retrieval and eventually over the wire stenting for duct recanalization and remodeling and bioloma drainage. For hepaticogastrostomy, the left liver was imaged from the proximal stomach, left duct punctured with a 19-gauge needle, a cholangiogram obtained revealing passage into the biloma, guidewire placed for tract dilation and fully covered metal stand placement between the left hepatic duct and the stomach, achieving acute control of leakage. Two weeks later, cholangiography was repeated through the mature hepaticogastrostomy and a guidewire integrally passed into the bioloma. The duodenoscope was removed and reintroduced alongside the wire for ERCP and retrograde cholangioscopy using a disposable cholangioscope. The cholangioscope was passed into the bioloma. The antegrade guidewire was identified, grasped with a tripod forceps, and retrieved through the downstream bile duct into the duodenum, where it was retrieved again and pulled up the duodenoscope working channel, so achieving re-canalization of the transected bile duct. Parallel cannulation alongside the previous wire allowed access into the bioloma, which was drained transpapillary with a 7-fringe double pigtail stand. The bile duct was stunted over the through-and-through wire with a 10-fringe, 12-centimeter plastic stand. The leakage completely ceased and the patient was discharged. Four weeks later, at ERCP, the transpapillary biliary stents were retrieved. Cholangiography revealed no leakage and reconnected the duct with a tight stricture. Bilateral stenting was performed placing a 8.5, 12-centimeter biliary stent into the right hepatic duct and a fully covered 6-centimeter by 10-centimeter metal stent into the left hepatic duct. At second outpatient revision, four months later, a completely remodeled bile duct was noted with minimal contour irregularity at the side of the previous transsection. Another 10-millimeter fully covered stent was placed to consolidate duct remodeling. In conclusion, hepatic gastrostomy avoids external biliary drainage in transected bile ducts, allowing acute leakage control and elective antigrade guideway access. Retrograde peritoneoscopy maximizes the chances of guideway retrieval across the transected bile duct and with adequate patient anatomic candidacy, multidisciplinary team support and operator expertise, this stage interventional EOS treatment strategy appears feasible and promising.

laparoscopic cholecystectomy

bile leakage

hepaticogastrostomy

ERCP

retroperitoneoscopy