A novel case of biliary common bile duct reconstruction by the rendezvous technique using endoscopic cholangioscopy and percutaneous cholangioscopy

Biliary tract injuries during cholecystectomy are a rare, but not exceptional, adverse event, with severe consequences. The Strasberg classification with Bismuth modification is most frequently used to classify biliary tract injuries ^{1 2} . Expertise in endoscopic, radiologic, and surgical management is required, especially for major biliary tract injuries ³ . A transhepatic-endoscopic approach is useful in difficult cases ^{4 5} . We aim to describe a new solution after failure of the standard rendezvous technique, namely double cholangioscopy rendezvous.

A 21-year-old woman developed jaundice 3 months after she underwent cholecystectomy for lithiasis. The patient was referred to our center after undergoing an initial endoscopic retrograde cholangiopancreatography (ERCP), which was unsuccessful because of a blockage below the hilum (Strasberg–Bismuth E2) ( Fig. 1 ). A repeat ERCP attempt also resulted in failure, and external percutaneous drainage was required, with an 8.5-Fr drain placed. The patient’s jaundice subsequently decreased.

Fig. 1 .

Magnetic resonance cholangiography image showing a Strasberg–Bismuth E2 stricture.

A joint decision was made by the gastroenterologists and surgeons to perform the rendezvous technique to avoid a hepaticojejunostomy with a high risk of secondary stricture because of its proximity to the convergence. The first attempt made at this procedure was unsuccessful, and the 8.5-Fr percutaneous drain was replaced with a 12-Fr drain ( Fig. 2 a ). A second attempt using simultaneous percutaneous cholangioscopy and ERCP was scheduled for a few days later ( Video 1 ), but this repeat classical rendezvous technique was a failure too. Attempts guided with cholangioscopy by the endoscopic route were also unsuccessful.

Fig. 2.

 Fluoroscopic images showing: a the 12-Fr external drain in the intrahepatic duct; b multiple endoscopic stents placed a few weeks after the initial reconstruction.

Video 1  After several failed rendezvous procedures, a novel rendezvous technique is performed using cholangioscopy for the endoscopic retrograde cholangiopancreatography to visualize the stricture, along with percutaneous cholangioscopy using a bronchoscope.

Download video file ^{(67.3MB, mp4)}

Cholangioscopy was used for ERCP to visualize the stricture, while percutaneous cholangioscopy was performed with a bronchoscope. A needle was used with the bronchoscope to puncture the stricture, and the common bile duct was found with a guidewire. The guidewire was then recovered by the ERCP approach, and a percutaneous internal/external drain (12 Fr) was inserted. A few weeks later, the percutaneous internal/external drain was exchanged with three 12-Fr plastic stents ( Fig. 2 b ), which were replaced every 4 months for a duration of 1 year.

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Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available. This section has its own submission website at https://mc.manuscriptcentral.com/e-videos