Impossible but true: complete transection of common bile duct treated with ERCP/percutaneous biliodigestive rendezvous

Bile duct injuries after laparoscopic cholecystectomy have been reported even after surgical procedures performed by expert surgeons. Mean rates have plateaued in the past 10 years (0.30 %–0.60 %). The Hannover classification (2015) is a modification of the Strasberg–Bismuth classification and allows a distinction between small injuries (bile leakage from the cystic duct or aberrant right sectoral branch) and serious injuries inflicted during laparoscopic cholecystectomy [1] [2]. The Hannover classification also provides discriminators for the localization of tangentially or completely transected bile ducts above or below the bifurcation of the hepatic duct, which is a major drawback of other classification systems.

Small injuries are usually treated with endoscopic retrograde cholangiopancreatography (ERCP) in which plastic stents are placed in the affected branch for a mean of 3–6 months and then extracted. Severe injuries, on the other hand, are always treated with surgery (Roux-en-Y choledocho-/hepaticojejunostomy or end-to-end laparoscopic reconstruction) [3] [4] [5]. So far, no nonsurgical approaches have been reported, except for one short report on leakage after hepatobiliary and pancreatic surgery (totally radiological percutaneous rendezvous).

A 60-year-old man who had undergone open cholecystectomy in another hospital and been discharged 2 days earlier was admitted to the emergency room of our hospital for acute abdomen, cholangitis, and a collection of bilious-looking fluid in the surgical drainage (> 700 mL/day). Abdominal computed tomography revealed a large perihepatic fluid collection and magnetic resonance imaging showed complete, severe leakage from the common bile duct, type D2 (Hannover classification) ([Video 1]). Laboratory investigation revealed high levels of bilirubin (total 12.00 mg/dL, direct 10.00 mg/dL), leukocytosis (22,000 × 10³/µL), and high levels of inflammatory markers.

Video 1 Complete transection of the common bile duct. Two plastic pig-tailed stents were inserted in the right and left main hepatic duct, and were later replaced with self-expandable metallic ones.

The patient was in a severely compromised clinical condition. The leakage was due to complex iatrogenic duct transection with excluded liver segments. Given this critical scenario, emergency ERCP/percutaneous biliodigestive rendezvous was attempted ([Video 1]). An alternative surgical approach was ready to be employed if the first approach failed.

By means of a gooseneck snare (Medtronic), we managed to achieve our aim. Two plastic pig-tailed stents (8.5 Fr, 12 cm) were successfully inserted in the right and left main hepatic duct and a bile bag draining from the subhepatic space was left ([Video 1]). In the following days cholangiography showed an improvement in the biliary leakage and a progressive reduction in the output of the bile bag. The second step was replacement of the plastic stents with self-expandable metallic ones (10 Fr, 12 cm) ([Video 1]).

The patient was discharged uneventfully 1 month later, and at 2-month follow-up cholangiography showed complete reconstruction of the biliary tree without any evidence of leakage ([Video 1]).

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995; 180: 101-125
• 2 Chun K. Recent classifications of the common bile duct injury. Korean J Hepatobiliary Pancreat Surg 2014; 18: 69-72
• 3 de Reuver PR, Busch OR, Rauws EA. et al. Long-term results of a primary end-to-end anastomosis in peroperative detected bile duct injury. J Gastrointest Surg 2007; 11: 296-302
• 4 Kwak BK, Choi HJ, You YK. et al. Laparoscopic end-to-end biliary reconstruction with T-tube for transected bile duct injury during laparoscopic cholecystectomy. Ann Surg Treat Res 2019; 96: 319-325
• 5 Mansueto G, Gatti FL, Boninsegna E. et al. Biliary leakage after hepatobiliary and pancreatic surgery: a classification system to guide the proper percutaneous treatment. Cardiovasc Intervent Radiol 2020; 43: 302-310

Publication History

Article published online:
08 September 2021