Repair of Strasburg type E bile duct injury via ARCP alone following laparoscopic cholecystectomy. A challenging case. Description Bile duct injury is a serious complication of laparoscopic cholecystectomy occurring up to 3% of cases, with the severe injuries including Strasburg type D and E accounting up to 0.5% of cases. Factors such as anatomical abnormalities, inflammatory changes, or surgical technique can elevate the risk. Early diagnosis and classification through endoscopic and imaging modalities are critical for determining the appropriate treatment pathway. Regardless of whether successfully repaired, quality of life may be diminished and the survival may be impaired. Strasburg classification categorizes PDIs based on the location and severity of the injury. It has 5 classes, class A, B, C, D, E. Class E1 means the transsection happened 2 cm away from the common hepatic duct. Repair approach depends on the class. Class A, B, C, D can be repaired by ARCP with different techniques including sphincterotomy, tinting, or nasal biliary drainage. The main purpose of this intervention is to reduce the transpipillary pressure gradient, which improves the transpipillary flow by diverting the extravasation to the intact biliary tract drainage. However, class E injuries most of the time will have devascularization and friable tissue and needs hepatobiliary surgery. So this report highlights a unique case of type E PDI successfully managed by using ARCP only without surgical intervention. Case Presentation A 39-year-old female patient presented with a Strasburg type E PDI following laparoscopic cholecystectomy performed outside the hospital. Prior to the presentation, a stint was placed in the CPD via ARCP for clinical thiasis. The following day, the patient had laparoscopic cholecystectomy, however, it was complicated by complete CPD transsection, leaving the stint and both ends of the CPD freely floating in the abdomen. So as we can see, the plastic stint is uncovered by the pile duct tissue. Upon her transfer to our facility, the patient had 10 out of 10 sharp abdominal pain mostly in the right upper quadrant, denied fever, nausea, and vomiting. On exam, it was remarkable for tenderness over the right upper quadrant. Left and right PCT drains showed bile-tinged serosanguinous drainage. Lapses were remarkable for leukocytosis and elevated liver enzymes. CT abdomen pelvis with IV contrast showed hepatomegaly and lung common pile duct stint in place from the common hepatic duct to the fourth portion of duodenum. Endoscopic method During the endoscopic intervention, a guide wire was advanced through the apolla to connect the proximal and distal segments of the transected CPD. Then a bridging stint was successfully placed to restore the pile flow, and end-to-end approximation of the transected bile duct segment was achieved. ERCB showing dye injection phase, confirming the pile duct injury by extravasation of the contrast. As we can see, we don't have the full anatomy of the biliary and multiple balloon speeds going through the transected CPD. Balloon cholangiogram confirming the hepatic ducts. Wire cannulation phase trying to connect both ends together, aiming to restore the anatomy, then the stint will be placed. advancing stent through the guide wire reaching to the left intrahepatic duct trying to divert the biliary drainage to that pathway. A stent was deployed confirming the placement of the stent from the left intrahepatic to the duodenum. Successful reconstruction was confirmed by MRCB one day after which showed no bile leak. As we can see the CPD stent in place without dye extravasation and this is the 3D structure showing there's no bile leak. Follow-up CT abdomen pelvis with IV contrast after four weeks showed resolved bile with the plans to repeat ERCB four weeks later for stent removal and or exchange. Clinical Implication. The 2020 guidelines of the World Society of Emergency Surgery recommend that patients with a major PDI is diagnosed in the immediate post-op period within 72 hours should undergo HIBATU digital stimuli repair. However recent guidelines do not address the role of ERCB alone in the management of the major PDI. This case demonstrates that advanced endoscopic techniques such as ERCB may effectively repair Strasburg type E PDIs without the need for surgical intervention when performed in advanced endoscopy unit. Conclusion. There is a potential use of advanced endoscopic interventions as a minimally invasive alternative for managing Strasburg type E PDI. Future clinical trials are needed to evaluate the safety and efficacy of the current standard approach compared to the ERCB guided approach. Thanks.

Strasburg type E bile duct injury

laparoscopic cholecystectomy

ERCP

endoscopic techniques

bile duct reconstruction