transhepatic endobiliary vascular intervention in a case of bleeding hepatico-jejunal varices. Bleeding hepatico-jejunal varices are a relatively rare but serious complication that can arise in patients who have undergone a hepatico-jejunostomy. Accessing the afferent loop in the context of hepatico-jejunal variceal bleeding is challenging due to the angulation of the jejunal jejunostomy, long limb length, and the presence of additions. The picture on the right depicts a post-Roux-en-Y anatomy, and the one on the left shows the plexus of varices at the hepatico-jejunostomy anastomotic site in keeping with portal cavernoma. A 54-year-old man with a history of mass-forming chronic pancreatitis complicated with distal bile duct structure who underwent biliary reconstruction, a Roux-en-Y hepatico-jejunostomy five years ago presented with melina. Bidirectional endoscopy and the initial CT angiography performed were unable to identify the source of the bleeding. This is the CT imaging that revealed multiple collateral veins seen at the porta hepatis in keeping with cavernous transformation of the portal vein. Single balloon endoscopy with fluoroscopic guidance failed to reach the hepatico-jejunostomy anastomosis due to the tight angulation encountered. After a multidisciplinary discussion, both endovascular approach, which included tips and portal vein stenting, as well as portal cable shunt surgery, was considered technically unfeasible due to the presence of extensive chronic mesentric thrombus. We proposed a two-step novel procedure to create a transhepatic tract to allow access and hemostasis of the bleeding hepatico-jejunal varices. First, a percutaneous transhepatic biliary tract creation is performed, followed by tract dilatation using over-the-wire dilators. Once the tract is mature, colidocoscopy and histoacryl glue injection for the bleeding varices is performed. This is a fluoroscopic video detailing the percutaneous transhepatic biliary tract creation via the left intrahepatic duct. Two days after the transhepatic biliary tract creation procedure, there was presence of hemobilia noted in the biliary drainage catheter, accompanied with clinical evidence of melina. We proceeded with a temporary tamponade using a CRE balloon catheter. Akin to the Sankstetten-Blackmore tube used in bleeding esophageal varices, this balloon catheter causes hemostasis by direct compression of the bleeding hepatico-jejunal varices. Here, the balloon is inflated at the level of the hepatico-jejunal site. Over the next few hours, patient demonstrated clinical improvement following resuscitative measures. A week later, we proceeded with sequential tract dilatation up to 16 French using over-the-wire dilators under fluoroscopic guidance. We then proceeded with the colidocoscopy procedure. The colidocoscope with a 2-millimeter working channel is advanced into the tract that was just dilated. At the hepatico-jejunostomy site, there were ectopic varices with stigmata of recent hemorrhage identified. After obtaining an optimal view of the varices, a combination of histoacryl glue and lipidol is injected into the varices. Here, a bleb is seen at the injection site. Another ectopic varix that is seen adjacent to the initial varix is also injected with histoacryl glue. Each injection is limited to one milliliter to prevent embolization. At this point, suction is avoided to prevent sucking glue into the suction channel. On reassessment two weeks later, a repeat histoacryl glue injection is performed to obliterate the remaining hepatico-jejunal varices. This is the endoscopic image of the remaining hepatico-jejunal varices. Stigmata of recent hemorrhage is clearly visible. This is a fluoroscopic image after histoacryl glue injection into the varices. Endoscopic evaluation after a month revealed regression of the varices with post-injection ulceration. The percutaneous transhepatic biliary tract allows access to the hepatico-jejunostomy anastomotic site in patients with bleeding varices when conventional methods fail. In patients with recurrent hepatico-jejunostomy variceal bleeding, this tract provides quicker access and optimal visualization for repeat hemostatic measures. The percutaneous transhepatic approach used in this procedure could theoretically be adopted for interventions in cases of biliary pathology with altered anatomy. Bleeding hepatico-jejunal varices can be challenging and requires a multidisciplinary approach. The transhepatic endobiliary vascular intervention is a two-step procedure that is technically feasible and allows access to an intervention in hepatico-jejunostomy varices. Further studies are needed to prove the safety and efficacy of this novel technique.

hepatico-jejunal varices

percutaneous transhepatic

histoacryl glue injection

balloon catheter tamponade

biliary anatomies intervention