Surgical Staple-Induced Biliary Duct Obstruction Following ROUX-EN-Y Hepaticojejunostomy: Successful Endoscopic Management

CASE REPORT A 25-year-old patient with a history of Roux-en-Y hepaticojejunostomy presented 2 months after the surgery with acute ascending cholangitis. Imaging confirmed distal common bile duct and anastomotic stenosis, and an internal-external percutaneous biliary drain was placed (Figure 1). Percutaneous cholangioscopy revealed a metallic surgical staple eroding into the distal bile duct, precluding conventional endoscopic therapy (Figure 2).Figure 1.: Magnetic resonance cholangiopancreatography (MRCP) showing hepaticojejunostomy (HJ) anastomotic stenosis (Arrow).Figure 2.: Fluoroscopic image highlighting surgical staples at the hepaticojejunostomy (HJ) stricture site (arrow).The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), during which staples were visualized near the ampullary region and removed. During the second ERCP, another staple was visualized near the hepaticojejunostomy anastomosis. The staple was not removed; instead, ductal dilation was performed, and a single plastic stent was placed. The patient remained symptomatic, and during the third ERCP, the retained staple and the stent were removed; the biliary tree was swept with an 11.5-mm extraction balloon, and the stenotic major papilla was dilated to 7 mm (Figure 3). After this intervention, the patient experienced resolution of symptoms. At follow-up, he remained clinically stable, with normalization of liver function tests, tolerance of a regular diet, stable weight, continued ursodiol therapy, and post-ERCP evaluation demonstrating no evidence of biliary obstruction (Figure 4).Figure 3.: Endoscopic view demonstrating removal of surgical staple (arrow) using a raptor forceps.Figure 4.: Endoscopic retrograde cholangiopancreatography after staple removal demonstrating a normal bile duct without obstruction.This case illustrates a rare complication of Roux-en-Y hepaticojejunostomy, in which surgical staples caused common bile duct obstruction. Most iatrogenic biliary strictures after hepaticojejunostomy arise from anastomotic narrowing rather than foreign body obstruction.1 Staple-induced biliary obstructions have been reported more commonly reported after laparoscopic cholecystectomy.2 In this case, the patient's biliary obstruction was likely multifactorial, with mechanical impingement, altered anatomy, and limited visualization contributing to the complication. Diagnosis was challenging because of the altered anatomy, necessitating percutaneous cholangioscopy for direct visualization. Endoscopic removal and stenting are first-line treatments for iatrogenic distal biliary strictures3 and were successfully performed in this case despite the Roux-en-Y anatomy. This case underscores the importance of a multidisciplinary approach and highlights minimally invasive endoscopic management as an effective alternative to repeat biliary surgery (Video 1). {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Surgical Staple-Induced Biliary Duct Obstruction Following Roux-EN-Y Hepaticojejunostomy: Successful Endoscopic Management","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_5xr9zw65"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} DISCLOSURES Author contributions: MU Khalid: Contributed to the conception and design of the work; Drafted the manuscript; Approved the final version to be published; Accepts accountability for all aspects of the work. S. Paski: Contributed to the acquisition of clinical data; Critically reviewed the manuscript for important intellectual content; Approved the final version to be published; Accepts accountability for all aspects of the work. R. Simon: Contributed to the acquisition of clinical data; Critically reviewed the manuscript for important intellectual content; Approved the final version to be published; Accepts accountability for all aspects of the work. H. Siddiki: Contributed to the analysis and interpretation of data; Critically reviewed the manuscript for important intellectual content; Approved the final version to be published; Accepts accountability for all aspects of the work. All authors meet ICMJE criteria for authorship. MUmair Khalid serves as the article guarantor and accepts full responsibility for the conduct of the study. Financial disclosure: None to report. Informed consent was obtained for this case report.