Abstract Background Postoperative biliary strictures are commonly related to accidental bile duct injuries or occur at the site of biliary anastomosis. The first-line treatment for benign biliary strictures is endoscopic therapy, which is less invasive and repeatable. However, recanalization for biliary complete obstruction is technically challenging to treat. The present report describes a successful case of treatment by extraluminal recanalization for postoperative biliary obstruction using a transseptal needle. Case presentation A 66-year-old woman had undergone caudal lobectomy for the treatment of hepatocellular carcinoma. The posterior segmental branch of the bile duct was injured and repaired intraoperatively. Three months after the surgery, the patient had developed biliary leakage from the right hepatic bile duct, resulting in complete biliary obstruction. Since intraluminal recanalization with conventional endoscopic and percutaneous approaches with a guidewire failed, extraluminal recanalization using a transseptal needle with an internal lumen via percutaneous approach was performed under fluoroscopic guidance. The left lateral inferior segmental duct was punctured, and an 8-F transseptal sheath was introduced into the ostium of right hepatic duct. A transseptal needle was advanced, and the right hepatic duct was punctured by targeting an inflated balloon that was placed at the end of the obstructed right hepatic bile duct. After confirming successful puncture using contrast agent injected through the internal lumen of the needle, a 0.014-in. guidewire was advanced into the right hepatic duct. Finally, an 8.5-F internal–external biliary drainage tube was successfully placed without complications. One month after the procedure, the drainage tube was replaced with a 10.2-F drainage tube to dilate the created tract. Subsequent endoscopic internalization was performed 5 months after the procedure. At the 1-year follow-up examination, there was no sign of biliary obstruction and recurrence of hepatocellular carcinoma. Conclusions Recanalization using a transseptal needle can be an alternative technique for rigid biliary obstruction when conventional techniques fail.
A 33-year-old male was introduced to our department to investigate the cause of downhill esophagus varices (Panel A) diagnosed 2 years ago during general medical checkup. He was implanted a pacemaker via left subclavian vein at the age of 16 due to congenital complete atrioventricular block. Contrast enhanced computed tomography showed occlusion from the innominate vein to the superior vena cava (SVC) and dilatation of the azygos vein, with varices around the esophagus (Panel B). Angiogram from above the SVC-right atrium (RA) junction showed a stenosis at the junction (Panel C), and SVC-RA pullback pressure examination showed a pressure gradient of 13 mmHg (Panel D) to the RA pressure at the stenosis sight. Downhill esophagus varices are a rare form mainly due to SVC obstruction, which in the current case was supposed to be induced by the pacemaker leads. As the SVC was totally occluded from the innominate vein, solely lead extraction without SVC reconstruction will not resolve the SVC obstruction. Resolving the stenosis at the SVC-RA has a possibility to reduce the elevated pressure. As the current varices staging were mild, the patient desired to perform close endoscopy follow-up and consider the heart operation when worsening of the varices.
