[Combined endoscopic and percutaneous transhepatic approach in postsurgical common bile duct occlusion]

Combined endoscopic and percutaneous transhepatic approach in postsurgical common bile duct occlusion.

A 48-year-old patient was transferred to our hospital suffering from acute cholangitis due to complete bile duct occlusion one year after a laparoscopic cholecystectomy. Main complaints were fever over 40;C and chills, accompanied by right upper quadrant abdominal pain and jaundice.

Cholestastic enzymes, transaminases and leucocytes were increased. Transabdominal utrasound showed massive dilatation of the intrahepatic bile ducts. ERCP was performed and revealed a complete and impassable obstruction of the proximal common bile duct.

The bile duct occlusion following cholecystectomy was the reason for the patient inverted question marks cholangitis. Neither via ERCP nor via the percutaneous transhepatic approach was it possible to make a communication between the proximal and the distal biliary system, none of the guidewires being able to pass the obstruction. However, we finally managed to pass the obstruction in a combined endoscopic-percutaneous transhepatic rendezvous technique. The patient received a percutaneous large-calibre plastic prosthesis (Yamakawa type). 4 months after the procedure the stenosis could hardly be detected.

Endoscopic treatment is successful in most patients with post-cholecystectomy bile duct strictures. Therefore, repeated surgery is usually not necessary. Even in complete bile duct occlusions, the combined endoscopic-percutaneous transhepatic method can re-open the obstruction and is therefore a possible alternative to surgery in selected cases.