Endoscopic Anastomosis Between the Cystic Duct Stump and a Severed Aberrant Right Hepatic Duct
Comments: A 57 year old patient underwent cholecystectomy and colonic resection for a neoplasm in November 2007. Post operative course was complicated by a post-operative biliary leak.
An ERCP was performed and showed a complete transaction of posterolateral sectorial bile duct.
Fistula output reduced significantly after a percutaneous drainage of the severed duct but a low volume leak eventually persisted after 15 days. Patient was referred to our Endoscopy Unit for the endoscopic treatment.
The severed duct stump was not identified in ERCP.
Therefore, the cystic duct stump was cannulated and very stiff guide-wire was used to reopen the cystic duct stump.
A diagnostic catheter was advanced and the stiff guide-wire was exchanged with a fully hydrophilic soft-angle-tip guide-wire. The guide-wire was gently maneuvered with back –and –fro and torch movement to pass through the CD stump into the peritoneum and therefore into the severed duct.
Once again cholangiography demonstrated leak from the aberrant duct.
The percutaneous tube was withdrawn.
A 4mm balloon was advanced over the wire and inflated to dilate the cystic stump and the new path between the cystic duct and the aberrant duct.
A guiding catheter was pushed into the postero-lateral bile duct and therefore a 10F 12cm long stent was placed to create an anastomosis between the severed duct and cystic duct stump.
Bile leak stopped immediately. Cholangiography after 24 hours did not demonstrate any contrast leak. The PTC tube and the sub hepatic drain were removed.
The stent was let in place for three months. At ERCP a long and tight stricture was observed, without any contrast leaks. Patient underwent re-stenting for an additional 3 months.
The stent was eventually removed, without any prior cholangiography.
This kind approach should not be generalized for all patients with post-operative major biliary lesions and should not be considered only as a rescue measure for the management of biliary leaks.
A long stricture is likely to be present at the level of the “anastomosis” between the cystic duct stump and the posterolateral duct.
Such a stricture is unlikely to be successfully treated endoscopically. Surgery will be scheduled in case of recurrent cholangitis.
| Contributed by: |
Guido Costamagna, MD Catholic University, Rome |
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Citation: Costamagna, G. (Jun 01 2009). Endoscopic Anastomosis Between the Cystic Duct Stump and a Severed Aberrant Right Hepatic Duct. The DAVE Project. Retrieved Feb, 9, 2010, from http://daveproject.org/viewfilms.cfm?film_id=863 Times viewed since Feb 2006: 1744 |
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