Commentary

Post-cholecystectomy complete transection of bile duct poses a significant management challenge that warrants surgical repair or percutaneous–endoscopic reconnection. Purely endoscopic reconnection, with staged internal biliary drainage using combined endoscopic retrograde cholangiopancreatography (ERCP) and endosonography followed by definitive endoscopic repair has been described.

In this E-Video article, Martinez and colleagues describe a purely endoscopic reconnection of a completely transected bile duct by means of endoscopic ultrasound (EUS)-guided rendezvous and ERCP in a single session. The difficulties in such a setting can be twofold. First, transgastric puncture of nondilated bile ducts is difficult. The authors used a 22-G needle with a 0.018-inch guidewire to circumvent this. However, manipulating a soft 0.018-inch guidewire can be quite challenging. Secondly where, as in this case, there is complete transection of the bile duct, the guidewire can repeatedly enter the contralateral bile duct or subhepatic space and usually requires retrieval via the distal bile duct by means of a basket under fluoroscopic or cholangioscopic guidance. Thus the antegrade advancement of a thin soft guidewire in this case may indicate possible residual communication of the parts of the transected bile duct. However, the authors should be congratulated for their tremendous effort, that has the potential to extend the current indications for EUS-guided biliary drainage in benign biliary disease beyond those of rendezvous in cases of failed cannulation or postoperative anatomy.

Publication History

Article published online:
29 March 2022