Extra-anatomical intraduodenal endoscopic-radiologic biliary rendezvous for treatment of iatrogenic complete stenosis of the common bile duct.

Minimally invasive radiologic–endoscopic recanalization or reconstruction of the common bile duct (CBD) for benign complete stenosis or complex iatrogenic lesions is routinely practiced at some tertiary centers [1,2]. Various techniques have been reported, including endoscopic ultrasound (EUS)-guided insertion of a magnet through a previous choledochoduodenostomy [1–4]. A 38-year-oldwomanwhohad undergone laparoscopic cholecystectomy 6 months earlier developed an iatrogenic biliary fistula with partial stenosis of the CBD. A biliary fully covered self-expanding metallic stent (FCSEMS) was placed for 2 months, but jaundice and pain recurred 3 months after its removal. Occlusive endoscopic retrograde cholangiography revealed complete stenosis at the mid CBD (●" Fig.1). A guidewire was maneuvered to perforate the CBD at a point distal to the stricture, and percutaneous transhepatic cholangiographic guidancewasused toperforate the hepatic duct with a guidewire at a point proximal to the stricture (●" Fig.2). However both guidewires tended to advance in the direction of the duodenal bulb, and several attempts to achieve a rendezvous in the subhepatic space failed. Therefore, we then advanced both guidewires along the preferential route to reach the duodenal bulb through the same hole, created by the guidewire (●" Fig.3a), thus avoiding significant duodenal injury. Next, with a Dormia basket that had been inserted endoscopically, the proximal guidewire was grasped (●" Fig.3a, ●" Fig.3b) and constant, controlled traction was applied to extra-anatomically establish continuity of the biliary tree (●" Fig.4a, ●" Fig.4b, ●" Fig.4c). An FCSEMS (Wallflex; Boston Scientific, Natick, Massachusetts, USA) was delivered for definitive treatment and scheduled to be replaced after 6 months (●" Fig.5). The patient was discharged Fig.2 a Percutaneous transhepatic cholangiogram showing common bile duct cutoff. b The guidewire that had been inserted percutaneously passed through the choledochal stenosis and reached duodenal bulb. Fig.1 Occlusive retrograde cholangiogram showing complete stenosis of the common bile duct (CBD) in a 38-year-old woman. This occurred after removal of a stent placed to manage an iatrogenic biliary fistula with partial stenosis of the CBD that had developed following laparoscopic cholecystectomy.