Drainage for complete obstruction of the posterior bile duct after pancreatoduodenectomy with a forward-viewing echoendoscope

The first-line treatment for hepaticojejunostomy anastomotic stenosis is balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography, which is difficult to perform in some cases ¹ , despite the usefulness of a salvage method using a forward-viewing (FV) echoendoscope ^{2 3} . Here, we report a case of endoscopic ultrasound-guided biliary drainage (EUS-BD) using am FV echoendoscope in a patient with complete obstruction of the right posterior hepatic duct after surgery.

A 50-year-old man underwent a pancreaticoduodenectomy for pancreatic head cancer. The patient presented with an infraportal anomaly in the right posterior bile duct ( Fig. 1 a, b ) ⁴ . Ignorance of this anomaly during a pancreaticoduodenectomy led to complete iatrogenic transection of the right posterior hepatic duct, leading to its complete obstruction and resulting in postoperative cholangitis development ( Fig. 2 a–c ). Percutaneous transhepatic biliary drainage (PTBD) was performed for cholangitis ( Fig. 2 d, e ); however, the guidewire was unable to advance from the PTBD side to the intestine owing to complete obstruction. Therefore, we decided to perform EUS-BD with an FV echoendoscope ( Video 1 ). An FV echoendoscope was inserted to visualize the complete obstruction near the hepaticojejunostomy anastomosis ( Fig. 3 a–c ). A 19G needle (EZ Shot 3 Plus; Olympus Medical Systems, Tokyo, Japan) was used to puncture the right posterior hepatic duct, and a 0.025-inch guidewire was inserted into the bile duct ( Fig. 4 a, b ). The fistula was dilated with a 6-mm balloon catheter (REN; Kaneka Medix Corp., Osaka, Japan), and a fully covered metal stent (BONASTENT M-Intraductal, 8 mm, 3 cm; Medicoʼs Hirata, Tokyo, Japan) was placed ( Fig. 4 c–e ). After stent placement, a good outflow of contrast from the PTBD to the intestinal side was observed. A few days later, the PTBD was removed ( Fig. 5 a–c ); no recurrence of cholangitis was observed, and the patient was discharged.

Fig. 1.

Preoperative magnetic resonance imaging showed an infraportal anomaly of the right posterior bile duct (arrow).

Fig. 2.

a–c Computed tomography scan images and schema showed the completely obstructed and dilated right posterior hepatic duct (arrow). a, b Axial and coronal images. d, e Radiographic image and schema showed the right posterior hepatic duct after percutaneous transhepatic biliary drainage placement.

Fig. 3.

a Radiographic image showed the forward-viewing echoendoscope inserted near the hepaticojejunostomy anastomosis. b Endoscopic image showed the hepaticojejunostomy anastomosis. c Endoscopic ultrasound image showed the right posterior hepatic duct (arrow) visualized near the hepaticojejunostomy anastomosis.

Fig. 4.

a Endoscopic ultrasound image showed puncture of the right posterior hepatic duct using a forward-viewing echoendoscope. b Radiographic image showed the insertion of a guidewire into the bile duct. c Radiographic image showed dilation of the fistula with a 6-mm balloon catheter. d, e Radiographic image and endoscopic image after the placement of a fully covered metal stent.

Fig. 5.

a Radiographic image showed contrast flow from the percutaneous transhepatic biliary drainage to the intestinal side. b, c Radiographic image and schema after percutaneous transhepatic biliary drainage removal.

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Endoscopic ultrasound-guided biliary drainage using a forward-viewing echoendoscope in a patient with complete obstruction of the right posterior hepatic duct after pancreaticoduodenectomy.

Video 1

Hence, EUS-BD with an FV echoendoscope may be a useful option for complete biliary obstruction caused by surgical procedures, as in the present case.

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