Balloon-Assisted Redirection: A Novel Endoscopic Technique for Complex Biliary Injury Post-Cholecystectomy

Case

A 52-year-old female presented with abdominal pain, nausea, and persistent bilious drainage (200–300 mL/day) for 30 days following open cholecystectomy. Three months earlier, she had biliary pancreatitis and choledocholithiasis, managed by endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and placement of a 10 Fr × 7 Cm biliary plastic stent. After symptomatic improvement, she underwent elective cholecystectomy at an outside hospital, which was converted into an open procedure due to dense adhesions, and a drain was placed in the gallbladder fossa.

Postoperatively, she continued to have high-output bilious drainage without jaundice. A repeat ERCP elsewhere showed stent migration, a tight common hepatic duct (CHD) proximal CBD stricture, and failure to access the upstream duct. She was referred to our center.

On admission, she was afebrile but nutritionally depleted. Magnetic resonance cholangiopancreatography revealed a 23-mm-long CHD-proximal CBD stricture and peri-cholecystic collection. Given the ongoing bile leak and poor surgical fitness, repeat ERCP was planned. Cholangiogram showed extravasation of contrast from the proximal CBD with a cutoff at the CHD site. The guidewire repeatedly entered into the leak site during ERCP. To prevent the entry of the guidewire into the leak, a novel “balloon-assisted redirection” technique was employed. A 0.025 guidewire (VisiGlide, Olympus, Tokyo, Japan) was passed through a percutaneous drain, followed by a biliary balloon catheter (Extractor, Boston Scientific, Massachusetts, United States). A balloon was positioned at the leak site and inflated (to 10 mm), which enabled the successful entry of the guidewire into the upstream duct. Both right and left ducts were opacified, and two biliary plastic stents were placed ([Fig. 1A–D]; [Video 1]). Bile output reduced to <20 mL/day within a week. The drain was removed at 2 weeks with good clinical recovery.

Fig. 1 (A–F) Post-cholecystectomy leak with high biliary stricture managed by endoscopic retrograde cholangiopancreatography (ERCP) using the novel “balloon-assisted redirection” technique placed via percutaneous drain. (A) Magnetic resonance cholangiopancreatography (MRCP) showed a normal lower CBD with a stricture of 23 mm length at CHD and upstream dilatation of intrahepatic biliary radicles (IHBR), and collection in the GB fossa. (B) ERCP revealed a normal lower CBD with a large amount of contrast extravasation from CHD; IHBR was not opacified. Percutaneous drain seen in situ. Contrast flow was seen in the percutaneous drain. (C) As the guidewire repeatedly entered into the leak site, a biliary balloon was introduced via percutaneous drain and inflated at the site of the leak to redirect the guidewire into the IHBR (green dotted line demarcates inflated balloon, and yellow dotted line demarcates balloon catheter passed through percutaneous drain). With the help of a balloon, the guidewire was successfully advanced into IHBR and contrast injection confirmed opacification. (D) A 7-Fr, 7-cm double pigtail plastic stents were placed into each of the right and left hepatic ducts to establish internal drainage.

Download Video

Video 1 Video demonstrating novel balloon-assisted redirection of the guidewire technique for management of the post-cholecystectomy bile leak with high biliary stricture.

Practical Implications for Endoscopists

• Post-cholecystectomy bile duct injuries can be effectively managed with ERCP.

• However, certain complex bile duct injuries pose significant challenges for endotherapy and often necessitate second surgery, which carries substantial mortality and morbidity.[1]

• The large defect in CBD prevents successful guidewire passage into the upstream or downstream duct during ERCP or PTBD approach, respectively.

• The novel balloon-assisted redirection technique, placed through an existing percutaneous drain tract, facilitates guidewire maneuvering and successful entry into the upstream intrahepatic duct during ERCP.

• Compared with coils or glue used percutaneously to block a leak, the balloon-assisted approach provides a simple, reproducible, and reversible alternative without depositing embolic material.[2] [3]

• References

• 1 Tringali A, Costa D, Ramai D. Endoscopic management of biliary leaks: Where are we now?. World J Gastrointest Endosc 2025; 17 (07) 107587
• 2 Wahaibi AA, Alnaamani K, Alkindi A, Qarshoubi IA. A novel endoscopic treatment of major bile duct leak. Int J Surg Case Rep 2014; 5 (04) 189-192
• 3 Dutra B, Welborn M, Thosani NC, Badillo R, DaVee T, Bhakta D. Endoscopic coil embolization for refractory intrahepatic biliary duct leak. ACG Case Rep J 2022; 9 (02) e00743

Publication History

Article published online:
06 January 2026