Combined endoscopic percutaneous rendezvous for biliary continuity curb the leak when traditional methods fail, primary author Shyam Thakkar. Additional authors are listed here, and all authors have no financial relationships with commercial interests to disclose. In the United States, over 700,000 laparoscopic cholecystectomies are performed annually. Iatrogenic bile duct injury is a major complication of laparoscopic cholecystectomy, where bile leaks occur in approximately 0.5% of cases, and bile duct injury occurring in 0.25% of patients. These cases have significant morbidity and mortality, with rates as high as 7% mortality in cases of common bile duct injury. When bile leak occurs, this is most optimally managed with ERCP, including biliary sphincterotomy and common bile duct stent placement. Occasionally, an internal-external catheter may be required through a percutaneous approach. When severe bile duct injuries occur, surgery is more likely to be necessary. However, present a novel method for achieving biliary continuity as an alternative to surgery in the case of a severe bile duct injury. A 65-year-old female underwent laparoscopic cholecystectomy. Two days later, she presented with abdominal pain and nausea. Blood work demonstrated active non-ST elevation MI, cross-sectional imaging demonstrated free intraperitoneal fluid, and HIDA scan confirms bile leak. The patient was taken for ERCP. On cholangiogram, a stricture is noted at the mid-CBD at the level of the surgical clip. There is free extravasation of dye upstream from the clip, demonstrating a severe bile duct injury with bile leak. A cholangioscope is introduced, and a stenosis is found at the mid-CBD corresponding to the level of the cholecystectomy clip. During her active myocardial infarction, the patient was deemed too unstable for full biliary exploration, and an emergent drain was placed. A percutaneous cholangiogram was performed, demonstrating free extravasation from the bifurcation of the biliary tree at the level of additional surgical clips. There was again no pacification of the common hepatic duct, confirming the suspicion of inadvertent common hepatic duct resection at the time of cholecystectomy. A PTC catheter was unable to be placed. The case was discussed at our multidisciplinary pancreatic biliary conference, and treatment options included reattempt at percutaneous catheter placement. However, this was deemed of low value given the biliary discontinuity that had been evident on prior cholangiograms, as well as the difficulty in accessing a peripheral duct. Additional option included surgical management. However, this was also deemed of low value given her active cardiac pathology. On literature review, a similar case had been described combining the percutaneous and endoscopic methods to reestablish continuity of a severely injured common bile duct, and it was elected to attempt a similar approach. First, a percutaneous cholangiogram is obtained, again demonstrating extravasation at the level of the superior clips. Following the cholangiogram, a wire is introduced into the intra-hepatic ducts and advanced across the level of the surgical clips into the free peritoneal space. Next ERCP is performed, and again cholangiogram demonstrates extravasation at the level of the inferior clip, as shown here. A wire is advanced beyond the clip, and the stenosis is then dilated using a dilating balloon, as shown here. This will allow for access for direct visualization cholangioscopy, and on direct visualization cholangioscopy, we now see a large opening at the site of previous stenosis. The cholangioscope can be advanced over the wire into the free peritoneal space. The wire from the percutaneous procedure is visualized here and will now be able to be grasped using a miniaturized forceps, as shown here. Once grasped, the wire is pulled through the cholangioscope, and this cholangioscope can then be removed, allowing for access between the extra- and intra-hepatic remnant biliary tree. Ultimately, a 10 millimeter by 10 centimeter fully covered self-expanding metal stent is deployed from the intra-hepatic biliary tree, through the free peritoneal space, and through the extra-hepatic common bile duct, and into the duodenum to reestablish continuity between the intra-hepatic and extra-hepatic biliary tree. Following this deployment, an occlusion cholangiogram is performed, demonstrating visualization of the intra-hepatic biliary tree without any extravasation. The percutaneous wire is then removed, and the procedure terminated. On follow-up, JP drain output decreased from 1200 cc's a day to 5 cc's a day. Repeat CT imaging revealed marked decrease in peritoneal fluid. Pneumobilia was seen in the right and left biliary trees, demonstrating appropriate stent function. The patient was ultimately discharged to home without complication. Technique Highlights. Intra-hepatic access was achieved using a percutaneous technique with simultaneous common bile duct access using an endoscopic approach. Direct visualization cholangioscopy was used to successfully identify the percutaneous wire. A miniature forceps was used to grab the percutaneous wire for effective rendezvous technique. A 10 mm by 10 cm fully covered metal stent was used to bridge the transected, completely resected, common hepatic duct and establish continuity between the intra-hepatic and extra-hepatic biliary tree. In conclusion, a multidisciplinary collaboration may provide effective alternatives to surgical management in cases of severe iatrogenic bile duct injury. This procedure demonstrates the feasibility of achieving biliary continuity in cases of biliary transection or resection. A combined endoscopic and percutaneous rendezvous procedure for biliary continuity, CURB, is a viable salvage option for achieving this continuity in patients who are not surgical candidates.

Combined Endoscopic Percutaneous Rendezvous for Biliary Continuity

CURB

severe bile duct injury

laparoscopic cholecystectomy complications

alternative to surgery