Post written by Sundeep Lakhtakia, MD, MNAMS, DM, FASGE, from the Department of Medical Gastroenterology, AIG Hospitals and Asian Institute of Gastroenterology, Hyderabad, Telangana, India.

A young woman who had surgical choledocho-duodenostomy 5 years ago for biliary adverse events soon after cholecystectomy presented with biliary obstruction. MRCP revealed a smooth mid-CBD stricture, intra-hepatic stone with bilateral intrahepatic biliary dilatation. ERCP confirmed biliary cut off at the common hepatic duct. She underwent PTBD, but contrast and guidewire could not pass across the tight biliary stenosis after few attempts. The external drainage catheter got dislodged after few weeks of indwell.

An EUS evaluation showed dilated CHD and bilateral IHBR, and an EUS-guided biliary access was achieved by transduodenal puncture just below the biliary confluence with 19-gauge needle. After obtaining cholangiogram, a 0.035-inch guidewire was passed through the needle into the left hepatic duct (LHD). Over the guidewire, a biliary duodenal fistula was created using 6F cystotome. A 4-cm fully covered SEMS was deployed under combined EUS and endoscopic guidance. There was no contralateral side obstruction despite FCSEMS marginally projecting into the LHD. A free flow of bile was noted along with contrast emptying from both hepatic ducts. An anchoring short 7F plastic stent was placed through the FCSEMS. After 6 weeks, FCSEMS was removed, leaving the plastic stent in situ. The patient remained asymptomatic during FCSEMS indwell period (6 weeks) and after its removal (at 10 months) when the plastic stent was also removed. On further follow-up of another 6 months, the patient remains fine with normal LFTs.

Post-cholecystectomy bile duct injuries are a common cause of benign biliary obstruction (BBO). Biliary drainage in surgically altered anatomy is difficult to manage by conventional ERCP and is frequently managed by PTBD or through balloon-assisted enteroscopy. In this young patient, the surgically created choledocho-duodenostomy anastomosis had completely closed, and both endoscopic and PTBD approaches failed. EUS-guided choledocho-duodenostomy using a FCSEMS bailed her out in a challenging clinical situation successfully.

EUS-guided bilio-enteric drainage using fully covered self-expanding metal stents can be considered in exceptional cases in benign biliary obstruction, when ERCP and percutaneous drainage fail. The beneficial outcome in early and medium term is encouraging.  

EUS-guided biliary intervention may be considered early in the course of management algorithm of benign biliary obstruction rather than after failure of conventional methods.

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