Post written by Manuel Perez-Miranda, MD, PhD, from Hospital Universitario Rio Hortega, Valladolid, Spain.

A patient with a transected bile duct after cholecystectomy presenting with high-output bile leakage was successfully treated with staged endoscopy. EUS-guided hepaticogastrostomy was used first to internalize externally diverted bile flow.

At a follow-up endoscopy, a cholangioscope by ERCP grasped a guidewire passed through the hepaticogastrostomy into a subhepatic biloma, achieving duct recanalization. During 3 subsequent outpatient ERCPs over a 10-month period, the transection gap was fully remodeled using a fully covered self-expandable metal stent. Duct healing was confirmed by cholangioscopy and sustained through a 9-month follow-up after removal of all biliary stents.

Definitive endoscopic repair of a completely transected bile duct is feasible in select instances. Acutely sick patients can avoid external biliary diversion (and its attendant inconveniences) and subsequent elective reconstructive surgery. From a technique standpoint, EUS-guided hepaticogastrostomy using antimigration fully covered stents and cholangioscopy to retrieve rendezvous guidewires is still relatively underused.

This staged endoscopic treatment approach requires expertise in combined use of interventional EUS and ERCP, institutional support, and careful multidisciplinary planning. Despite apparent technical complexity, the obvious clinical benefits to the relatively few patients who have this condition clearly warrant the effort involved.

Second outpatient ERCP revision after a sequential 4-month stenting period with bilateral plastic and covered metal stents, showing a completely remodeled bile duct with minimal contour irregularity adjacent to surgical clips.

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