Uncoiling the Mystery of Bile Duct Blockage: A Case of Biliary Obstruction

CASE REPORT Bile duct injury during laparoscopic cholecystectomy is a well-recognized surgical adverse event, with an incidence reported between 0.3% and 0.7%,1 that may require biliary reconstruction.2 We present the case of a 55-year-old man with acute gallstone cholecystitis who underwent a laparoscopic cholecystectomy converted to open laparotomy with Roux-en-Y hepaticojejunostomy and subsequent right hepatic artery pseudoaneurysm requiring coil embolization (Figure 1) and laparoscopic washout and hematoma evacuation.Figure 1.: Abdominal X-ray revealing the coils in the right upper quadrant, the black arrow.One year later, he presented with jaundice. Magnetic resonance cholangiopancreatography demonstrated narrowing at the hepaticojejunostomy and intrahepatic duct dilation (Figure 2).Figure 2.: A magnetic resonance cholangiopancreatography picture, the white arrow points to a stricture of the hepaticojejunostomy anastomosis.Because of the altered anatomy, standard endoscopic retrograde cholangiopancreatography (ERCP) with a duodenoscope could not be performed (Video 1). Balloon-assisted enteroscopy was selected over device-assisted endoscopic ultrasound (EUS)-guided intervention or percutaneous cholangioscopy to safely navigate the surgical limb and provide direct access to the anastomosis. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Biliary reconstruction via Roux-en-Y hepaticojejunostomy. This video demonstrates the reconstruction of the biliary tract following bile duct resection.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_03i1uhns"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Balloon-assisted enteroscopy was employed to reach the hepaticojejunostomy in the Roux limb. Metallic coils were visualized eroding into the jejunum (Video 2 [01:40]) (Figure 3), causing a stricture at the hepaticojejunostomy. This was treated with ERCP (Video 2). The stricture was successfully managed with a plastic biliary stent (Video 2 [03:49]) rather than a metallic stent to minimize the risk of any further erosion and to allow for a future stent exchange. This resulted in improved total bilirubin and resolution of biliary obstruction (Figure 4). {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"Double balloon enteroscopy for hepaticojejunostomy stricture. The video demonstrates the endoscopic management of coil erosion and stricture dilation, followed by the placement of a plastic biliary stent.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_87090dul"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Figure 3.: A white arrow points at the embolization coils obstructing the hepaticojejunostomy anastomosis; the black arrow points at the 7 French by 7-cm biliary plastic stent put in place to ensure patency.Figure 4.: A cholangiogram obtained during the procedure. The white points at the anastomotic stricture, whereas the black arrow points at the coils causing obstruction.This case highlights 2 rare but serious complications: pseudoaneurysmal bleeding after percutaneous transhepatic cholangiography (PTC)3 drain placement and subsequent coil erosion into a biliary-enteric anastomosis.4 Management required close collaboration between interventional radiology, surgery, and advanced endoscopy. The use of balloon-assisted ERCP enabled safe access to the hepaticojejunostomy, allowing minimally invasive treatment of the stricture. Awareness of these uncommon complications is crucial. Specifically, a history of prior vascular embolization should trigger active suspicion for coil-related complications in patients with biliary-enteric anastomoses presenting with obstruction. Endoscopic therapy can provide effective, less invasive solutions even in patients with altered anatomy and complex postsurgical sequelae. DISCLOSURES Author contributions: H. Musood: writing the manuscript, editing the video, reviewing the manuscript and the video. S. Hamarsheh: writing the manuscript and reviewing the video. S. Paski: coming up with the research question and reviewing the video and manuscript. R. Simon: coming up with the research question and reviewing the video and manuscript. H. Siddiki: coming up with the research question, making animations, editing the video, writing the manuscript, and reviewing the outcome and is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.