Endoscopic ultrasound-guided hepaticoduodenostomy for the management of iatrogenic bile duct injury related to cholecystectomy: a report of two cases

The management of bile duct injuries (BDIs) involves endoscopic and radiologic interventions, with surgery reserved for complex cases [1]. We present two cases of BDI managed with endoscopic ultrasound-guided hepaticoduodenostomy (EUS-HDS).

Case 1: A 77-year-old patient underwent a cholecystectomy complicated by an injury to the common bile duct. A surgical choledochoduodenostomy was performed. One year later, the patient developed cholestasis due to a strictured anastomosis. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous biliary drainage failed to traverse the anastomosis. EUS-hepaticogastrostomy was performed. Two weeks later, a nasobiliary catheter through the hepaticogastrostomy was used to distend the common hepatic duct (CHD) with normal saline. Linear EUS, from the duodenal bulb, enabled CHD puncture. A guidewire was advanced into the hepatic duct, followed by insertion of a 6-Fr cystotome and a 4-cm covered biliary stent ([Video 1]). No complications occurred. The stent was later replaced with double-pigtail stents, exchanged every three months, over one year.

Endoscopic ultrasound-guided choledochoduodenostomy procedure for the management of a post-cholecystectomy bile duct injury after failed endoscopic retrograde cholangiopancreatography and percutaneous biliary drainage.Video 1

Case 2: A 75-year-old patient had a BDI (Strasberg D) during cholecystectomy, managed with surgical hepaticoduodenal anastomosis. Six months later, cholestasis and dilation of right hepatic ducts (RHDs) were noted ([Fig. 1]). During endoscopic retrograde cholangiopancreatography, cannulation of the surgical anastomosis revealed exclusive drainage of the left hepatic ducts. A percutaneous drain with cholangioscopic assistance also failed to traverse the anastomosis. The RHDs were likely excluded. A percutaneous drain was placed for RHD distension. Under EUS guidance, the RHDs were punctured with a 19G needle. The hepaticoduodenal tract was dilated with a cystotome and a 6-mm balloon. Two double-pigtail stents were subsequently placed through the hepatobiliary tract orifice and exchanged every three months for one year ([Fig. 2]).

Fig. 1 a Abdominal computed tomography image showing isolated right hepatic duct dilation. b Cholangiography during percutaneous biliary drainage showing dilation of the right hepatic ducts, which are excluded from the remaining biliary tree.

Fig. 2 a Right bile duct puncture via a 19G fine-needle aspiration needle. b Fistula dilation using a 6-Fr cystotome. c Fistula dilation with a 6-mm biliary dilation balloon. d Insertion of the first double-pigtail plastic stent. e Fluoroscopic view of two double plastic stents through the hepaticoduodenal anastomosis. f Endoscopic view of the plastic stents in place.

We presented two cases of successful bile duct reconstruction using EUS-HDS after failed endoscopic and percutaneous interventions. This technique offers a minimally invasive alternative to surgical reconstruction in complex BDI. Larger series are still needed to assess the role of EUS-HDS in this indication.

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Artikel online veröffentlicht:
09. September 2025

• Reference

• 1 de’Angelis N, Catena F, Memeo R. et al. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg 2021; 16: 30