Post written by Thomas Tielleman, MD, from the University of Texas Southwestern Medical Center, Dallas, Texas, USA.

This is a case of a 48-year-old man who underwent cholecystectomy complicated by hemoperitoneum requiring take-backs to the operating room. A complete bile duct transection ultimately complicated the surgeries. Cholangiography from ERCP and percutaneous transhepatic cholangiography confirmed a large bile duct transection, and the patient was deemed no longer a surgical candidate because of concern for hostile abdomen.

Our video demonstrates a rendezvous ERCP procedure completed by placing a wire across the proximal transection into the peritoneum via the patient’s percutaneous biliary drain. The wire was subsequently retrieved via ERCP by advancing the cholangioscope through the distal transection and into the peritoneum, thus allowing for a wire to traverse across the entire transection.

However, given the length of the transection, 1 covered metal stent was not long enough to bridge the entirety of the transection. A suprapapillary-covered metal stent within the first stent was required to bridge the transection. Over time, the bile duct was noted to reconstitute and heal, permitting removal of all indwelling stents and preventing the need for further drains or surgery.

This case demonstrates a number of unique points:

• Despite a complete bile duct transection, successful bridging of the transection with a fully covered metal stent can create a scaffolding to allow for the bile duct to reconstitute. We hypothesize that the prolonged stenting permitted the formation of fibrotic scar/granulation tissue to enable reconnection of the transected bile duct. To date, the patient has not required stenting or repeat interventions in 23 months of follow-up.
• When a large transection cannot be bridged with 1 covered metal stent, a second stent can be placed suprapapillary within the first stent for complete bridging of the transection. In this case, we used 2 different stents: a Conmed Viabil stent (Elkton, Md, USA) with antimigration flaps to support stability outside the ampulla and a Boston Scientific WallFlex stent (Galway, Ireland) with 12-mm flanges to help the 12-mm flange open within the 10-mm diameter of the Viabil for further stability and migration risk reduction.

This case shows that endoscopic management of a complete bile duct transection is feasible and can have long-term success. Although surgical management is the typical management for a complete bile duct transection, it should be noted that endoscopic options exist, especially in patients who are deemed not surgical candidates.

Complete resolution of the common hepatic duct stricture after serial dilations. No further bile leak was present.

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