Annual Scientific Meeting
Introduction: A 64-year-old female with past history of pylorus-preserving pancreaticoduodenectomy for pancreatic adenocarcinoma presented for endoscopic management of anastomotic bile leak and suspected stricture at the hepaticojejunostomy which persisted despite surgical and percutaneous intervention.
Case Description/Methods: At the time of her surgery she was noted to have bile leakage from the new hepaticojejunostomy anastomosis, which was managed with intraoperative revision of the anastomosis and placement of a T-tube. On follow up after her surgery, she continued to have bilious drainage from her drains and was referred to interventional radiology for percutaneous transhepatic cholangiography. Cholangiogram demonstrated a significant leak from the anastomosis into a new subhepatic fluid collection. A percutaneous drainage catheter was placed. On subsequent catheter change, it was also noted that the biliary catheter was actually placed into a fluid collection adjacent to the small bowel and not across the hepaticojejunostomy. Internalization of the biliary catheter was unsuccessful as no flow of contrast from the bile duct to the jejunal limb could be identified.
Her course was also complicated by episodes of cholangitis. To manage the persistent anastomotic leak, ERCP was performed. An adult colonoscope was advanced to the hepaticojejunostomy, which appeared widely patent. Contrast injection through the existing external percutaneous drain in the right hepatic duct confirmed complete distal occlusion of the duct without any contrast passage into the jejunum. Careful exam of anastomosis revealed sutures located superior to the hepaticojejunostomy. A 0.018 inch hydrophilic wire was advanced anterograde alongside the external drain under fluoroscopic guidance. This was unable to be passed into the small bowel but advancement of the wire resulted in a bulge in the mucosa seen endoscopically in the area of sutures, confirming the diagnosis of inadvertent surgical closure of right system. To gain access to the right biliary system, a choleodochojejunostomy was created using a needle knife in the area of the bulge created by the antegrade passage of wire through percutaneous tract. This allowed a 10 mm by 4 cm fully covered metal biliary stent to be deployed into the right hepatic duct across the newly created hepaticojejunostomy.
Discussion: In this case, we describe the endoscopic diagnosis and treatment of an iatrogenic biliary stricture leading to persistent anastomotic leak after pancreaticoduodectomy.