Transpapillary/Transfistular Drainage for Two Refractory Postoperative Right-Lobe Bilomas: A Case Report

We report a case of two refractory postoperative right-lobe bilomas that were successfully treated with transpapillary/transfistular (TP/TF) drainage. A 57-year-old man developed two bilomas (segments 6 and 7) after repeated hepatectomy for colorectal liver metastases. Initial endoscopic retrograde cholangiopancreatography with endoscopic nasobiliary drainage (ENBD) was performed; however, biloma enlargement was observed despite ENBD placement, prompting a switch to TP/TF drainage. Two 5-Fr pigtail-type ENBD tubes were placed within the biloma cavities, followed by internalization after confirmed biloma regression (B6: from 93 to 38 mm, B7: from 71 to 28 mm). As the leak improved from high-grade to low-grade, the drainage strategy was modified to plastic stent placement in the B7 bile duct, ultimately achieving complete biloma resolution approximately 8 months after TP/TF drainage. Stent-free status has been maintained for 13 months, with a total follow-up of 21 months. This case demonstrates that TP/TF drainage is a feasible and effective option for multiple right-lobe bilomas, particularly when endoscopic ultrasound-guided transmural drainage would require multiple transmural procedures, allowing endoscopic treatment to be completed without percutaneous drainage.