Cholangioscopic reconstruction of a partially transected bile duct due to postcholocystectomy injury. Laparoscopic cholecystectomy is the surgical modality of choice for symptomatic gallstone disease. Bile duct injuries are rare, but serious complications that may occur in around 0.4 to 1.2% cases. ERCP is one of the first-line tools in the management of post-operative bile duct injuries. Here we show the utility of cholangioscopy for bile duct reconstruction in post-operative injury, causing biliary structure with leak. A 46-year-old female was referred to a unit after a complicated laparoscopic cholecystectomy elsewhere. On post-operative day 1, the patient had developed pain abdomen and vomiting with altered liver tests. MRCP was performed, which showed features of biliary obstruction at the level of the high lib with dilated right and left intrahepatic ducts. A possibility of bile duct narrowing due to surgical clip was considered. A diagnostic laparoscopy was performed, where surgical clips were removed. On-table ERCP was done during the same setting and the right anterior segment was drained with a plastic stent. Although there was mild improvement in her LFTs post-ERCP, she complained of pain abdomen and fever and was referred to a unit for further management. At presentation, she was ectric and the LFT showed a cholestatic pattern of injury. The total bilirubin was 2.6, SGOT and SGPT was 169 and 191 and the ALP was also elevated to around 387. She complained of pain abdomen and intermittent fever. MRCP at her centre showed post-cholestectomy status with a small 2 in 2 centimetre collection in the GB fossa and a high lars structure with dilatation of both right and left intrahepatic ducts. A plastic stent was noted extending from the right anterior duct to the duodenum. The right anterior duct was less dilated in view of the stent in place. Note was also made of a possible triple confluence with the right anterior, the right posterior and the left hepatic duct all emptying into the common hepatic duct at the same level. After a multidisciplinary discussion, it was decided to repeat ERCP for this patient with drainage of all the three ductal systems in view of high lar obstruction with cholangitis. The previously placed stent was noted with adjacent clips on fluoroscopy. The stent was removed with snare followed by biliary cannulation of the sphingotomised papilla. A guide wire was passed into what we wrongly assumed was the right anterior duct. However, subsequent cholangiogram showed that there was significant leakage of contrast at the level of the hilum with minimal contrast tracking across the ductal system. In this image, there is significant leakage of contrast with the cannula seen in the false tract. Subsequent attempts at cannulating the other ducts failed as the wire kept traversing outside of the biliary system, possibly through the disrupted bile duct. A possibility of bile duct dehiscence or partial transection was considered and after discussing with the relatives, a decision was made to go ahead with direct cholangioscopy and selective cannulation of both the right ducts and the left ductal system under vision. The interventional radiology team was kept on standby for an external drainage or rendezvous of the left ductal system during the same setting in case cholangioscopy failed. Cholangioscopy showed a normal appearance of the distal bile duct mucosa with cystic duct orifice adjacent to it. Extensive ulcers with sloughing mucosa was noted in the proximal bile duct. A large wall defect on the lateral wall of the bile duct at the level of the hilum was noted. The confluence of openings of the right anterior, the right posterior and the left hepatic duct could be visualized across the disruption. Under direct visualization, an O3-5 guide wire was placed deep into the right anterior system. After exchanging the wire with the cholangioscope, the cholangioscope was reinserted and the left ductal system and the right posterior system were sequentially drained. This fluoroscopy image shows guide wire in the right anterior system and the cholangioscope with guide wire in the left ductal system. The guide wires were kept in place while exchanging the spy scope. Fluoroscopy shows placement of guide wires in all the three ductal systems in this image. Subsequently, three 7-fringe into 7 centimeters double pigtail plastic stents were placed over the guide wires. The final position of the stents were confirmed on fluoroscopy. The patient's post-procedure condition was stable with no fever and gradual resolution of jaundice. A CT abdomen was taken the next day. CT scan confirmed the position of the stents in all the three ductal systems with a small GB fossa collection. The patient was discharged after one week of antibiotics. A repeat ultrasound abdomen after one month showed complete resolution of the collection with a normal LFT. In conclusion, post-cholecystectomy bile duct injuries, though rare, may cause significant morbidity and mortality. Cholangioscopy is an invaluable asset in such conditions where selective ductal cannulation is required for complete drainage of intrahepatic ducts.

cholangioscopy

bile duct injury

post-cholecystectomy

ERCP

biliary obstruction