Endoscopic ultrasound-guided rendezvous for extrahepatic bile duct recanalization after surgical transection

A 36-year-old woman developed jaundice, fever, and biliary leak after laparoscopic cholecystectomy. Endoscopic retrograde cholangiopancreatography (ERCP) (Video 1) identified massive extravasation of contrast into the peritoneum through a large fistula, without filling of the proximal biliary tract (Fig. 1). Cholangioscopy (SpyGlass; Boston Scientific Corp., Marlborough, Massachusetts, USA) showed the confluence between the hepatic and cystic ducts, and the peritoneal space was accessed through a complete transection of the hepatic duct (Fig. 2), with identification of the percutaneous surgical catheter and the liver. The proximal aspect of the transected hepatic duct could not be found with the cholangioscope. Using endoscopic ultrasound (EUS), the proximal and distal segments of the extrahepatic bile duct were identified, separated by a 1.5-cm-diameter collection. Transgastric puncture of the intrahepatic bile duct with a 22-G needle was performed, hindered by lack of duct dilation. A 0.018-inch guidewire was advanced anterogradely through the transection into the distal common bile duct and duodenum. The EUS-guided rendezvous was finally completed and an 80 × 10-mm fully covered metal stent was deployed in the subsequent ERCP (Fig. 3). The proximal end was placed immediately distal to the biliary confluence and the distal end into the duodenal lumen, securing bilateral biliary drainage. The patientʼs jaundice resolved within a few days, and 6 months after discharge the patient remains asymptomatic.