Bile duct injuries can occur at various sites, and the Strasberg classification is
useful in considering their treatment strategy [1 ]. A Strasberg Type B injury is a bile duct obstruction that commonly occurs from
the atypical right hepatic duct, and its endoscopic treatment is difficult [2 ].
A 70-year-old man who underwent pancreaticoduodenectomy for ampullary carcinoma was
referred to our department because of abdominal pain and fever. Computed tomography
and magnetic resonance cholangiopancreatography showed a fluid collection on the liver
surface and dilation of the right anterior hepatic duct, resulting in a diagnosis
of cholangitis and bile leakage ([Fig. 1 ]). Although a double-balloon endoscope-assisted endoscopic retrograde cholangiopancreatography
(ERCP) was performed, the right anterior hepatic duct could not be identified ([Fig. 2 ]). Percutaneous transhepatic biliary drainage (PTBD) was performed, resulting in
symptomatic improvement ([Fig. 3 ]). A review of the preoperative images revealed a variation in the right anterior
bile duct, which was ligated during surgery, resulting in complete occlusion
Fig. 1 Computed tomography and magnetic resonance cholangiopancreatography showed a fluid
collection on the liver surface and dilation of the right anterior hepatic duct (arrows).
Fig. 2 Although a double-balloon endoscope-assisted endoscopic retrograde cholangiopancreatography
was performed, the right anterior hepatic duct could not be identified.
Fig. 3 Percutaneous transhepatic biliary drainage was performed for the right anterior hepatic
duct.
For the internal drainage, we attempted an endoscopic ultrasound (EUS)-guided hepaticojejunostomy.
A forward-viewing echoendoscope (TGF-UC260J; Olympus, Tokyo, Japan) was inserted along
a nasobiliary drainage tube placed in the left hepatic duct ([Video 1 ]). After bile duct puncture with a fine-needle aspiration (FNA) needle, a guidewire
was placed into B8 and the puncture site was dilated with a drill dilator (Tornus
ES; Asahi Intec, Aichi, Japan). An additional guidewire was then placed into B5 using
a double-lumen catheter (PIOLAX, Tokyo, Japan). The puncture site was dilated with
a balloon catheter, followed by placement of a 7-Fr plastic stent and an 8-mm-diameter
fully covered metal stent (M-Intraductal; Medico’s Hirata Inc., Osaka, Japan) ([Fig. 4 ]). The PTBD catheter was removed and the patient was discharged two days postoperatively.
Hepaticojejunostomy using a forward-viewing echoendoscope is a promising treatment
option for a complete obstruction associated with a postoperative bile duct injury.
Endoscopic ultrasound-guided hepaticojejunostomy was performed using a forward-viewing
echoendoscope. The dilated right anterior branch was punctured with a fine-needle
aspiration needle, followed by dilation of the puncture site and stent placement.Video
1
Fig. 4 A 7-Fr plastic stent and an 8-mm-diameter fully covered metal stent were placed in
a side-by-side fashion.
Endoscopy_UCTN_Code_TTT_1AS_2AH
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