Multidisciplinary Management of Complicated Hepaticojejunostomy Stricture: A Case Report

Introduction: Hepaticojejunostomy (HJ) stricture is an infrequent complication observed after pancreaticoduodenectomy (PD). Management is initially attempted by percutaneous biliary dilatation and short-term stenting. Success rates are reported 88%; complications may arise despite proper management.

Case: A 64-year-old female with impression of pancreatic malignancy was referred to our institution. PD due to invasive pancreatic adenocarcinoma was complicated by a bile leak, subsequent sepsis, and bacteremia needing multiple intravenous (IV) antibiotic therapy as well as intensive care unit admission.

Percutaneous transhepatic cholangiography performed 2 weeks after surgery demonstrated biloma formation and bile leak from HJ, which was managed by placement of bagged internal–external biliary catheter. During the exchange of aforementioned catheter after 1 month of placement, the internalization was failed and external catheter was placed instead. The endoscopic retrograde cholangiopancreatography was planned and confirmed stricture at HJ as well as stenosis of right hepatic duct which was dilated by 8.5 mm balloon. Injection of the contrast through external percutaneous drain confirmed complete stricture of left hepatic duct. The percutaneous drain was further used to access the HJ from left hepatic duct for creation of choledochojejunostomy with needle knife. The choledochojejunostomy was secured with a 10 mm × 4 cm metal biliary stent assuring biliary drainage. The patient’s condition was complicated by enterococcal bacteremia requiring IV antibiotics. Upon completion of the treatment, the patient was discharged and further adjuvant therapy was discussed.

Conclusion: This case report presents a rare early stricture of HJ as well as biliary leak, resulting in multiple complications which was managed multidisciplinarily.

No conflict of interest has been declared by the author(s).