Hepaticojejunostomy and long-term interventional treatment for recurrent biliary stricture after proximal bile duct injury: A case report

Abstract

BACKGROUND

Proximal bile duct injury (BDI), which often occurs after laparoscopic cholecystectomy (LC), can lead to complex biliary stricture and recurrent cholangitis. This case report presented a 39-year-old woman who experienced proximal BDI during LC in 2017, leading to multiple episodes of cholangitis and subsequent hepaticojejunostomy in 2018. Despite these interventions, persistent biliary complications necessitated repeated hospital admissions and antibiotic treatment. Imaging studies revealed persistent stricture at the site of hepaticojejunostomy, prompting a series of percutaneous procedures, including balloon dilatation and biliary drainage. In August 2024, she underwent biodegradable biliary stenting, which significantly improved her condition. Subsequently, she remained clinically stable for 5 months without further episodes of cholangitis and had improved liver function tests. This case highlighted the complexities of managing postinjury biliary stricture, underscored the potential of biodegradable stents as an effective treatment option, and emphasized the need for a multidisciplinary approach in managing such complications. Long-term follow-up is essential for monitoring treatment effectiveness and preventing recurrence.

CASE SUMMARY

A 39-year-old female had a routine LC in 2017. The patient sustained a proximal BDI during the surgery. In the months that followed, recurrent bouts of cholangitis occurred. A hepaticojejunostomy biliary reconstruction was performed in 2018. However, hepatic cholangitis persisted. In 2021 and 2022, MRCP scans revealed biliary stasis, duct dilation, and a stricture at the hepaticojejunostomy site. A subsequent percutaneous transhepatic cholangiography (PTC) confirmed these findings and led to drain placement. The treatment included internal and external biliary drain placements, repeated balloon dilations of the stricture, percutaneous transhepatic cholangioscopy to extract intrahepatic lithiasis, and insertion of a biodegradable biliary stent. Since the first PTC intervention, there have been no hospital admissions for cholangitis. Liver function tests showed improvement, and for five months following the biodegradable stenting, the condition remained stable. Long-term surveillance with regular imaging and blood work has been emphasized. The final diagnosis is recurrent biliary stricture secondary to proximal BDI. Treatment, including hepaticojejunostomy, repeated PTC with balloon dilation, and biodegradable biliary stenting, has led to complete drainage of the biliary system. Ongoing follow-up remains crucial for monitoring the patient's progress and maintaining their health.

CONCLUSION

This case demonstrated how strictures and recurrent cholangitis complicate the management of BDI after LC. A customized and multidisciplinary approach to control chronic biliary disease was proven effective, as shown by the patient’s good outcome. This was achieved by integrating balloon dilatation sessions, biliary drainage, stone clearing, and biodegradable stent placement. Long-term follow-up and continued monitoring remain essential to ensure patient stability and prevent further complications.

Key Words: Biliary stricture; Hepaticojejunostomy; Bile duct injury; Biliary stent; Biodegradable stents; Magnetic resonance cholangiopancreatography

Core Tip: Effective management of recurrent biliary stricture following proximal bile duct injury requires a multidisciplinary approach, including timely surgical intervention, such as hepaticojejunostomy, and regular imaging using advanced techniques, such as magnetic resonance cholangiopancreatography. Incorporating innovative treatment modalities, such as biodegradable biliary stenting, can significantly improve patient outcomes by enhancing patency without the need for stent removal. Regular follow-up visits are crucial to assess stricture remodeling and prevent recurrence. Clinicians should remain vigilant for signs of cholangitis and be prepared to implement a combination of endoscopic and percutaneous interventions to ensure optimal management of complex biliary complications.

INTRODUCTION

Proximal biliary injury can often lead to complex biliary structuring disease and is most commonly managed by hepaticojejunostomy as the definitive treatment. However, the prevalence of stricture 2 years after hepaticojejunostomy was estimated to be 12.5%[1]. Hepaticojejunostomy strictures can be challenging due to the limitations of endoscopic techniques and usually require multiple percutaneous cholangiography procedures. A common therapeutic strategy for postoperative anastomotic strictures is balloon/bougie dilatation, which has a success rate of 70%. The advent of biodegradable stents has greatly improved outcomes, with success rates as high as 85%-95% in specialized centers[2]. Biodegradable stents present compelling advantages over conventional options, positioning them as a superior choice for treating biliary strictures. These innovative stents eliminate the need for removal procedures, significantly reducing patient discomfort and healthcare costs. Their unique properties result in a lower migration risk, enhancing patient safety and treatment efficacy. Importantly, biodegradable stents show potential for improved long-term patency rates, addressing a critical challenge in biliary stricture management. The gradual dissolution of these stents also minimizes complications associated with long-term placement, a common issue with conventional metal and plastic stents. While conventional stents have a more established history and provide immediate strong radial force, biodegradable alternatives offer a more holistic, patient-centered approach. Although plastic stents may be less expensive initially, the overall cost-effectiveness of biodegradable stents becomes apparent when considering reduced follow-up procedures and complications. Early clinical data demonstrates promising short-term patency rates and lower complication rates for biodegradable stents, suggesting a paradigm shift in biliary stricture treatment. As ongoing research continues to yield long-term data, it is increasingly evident that biodegradable stents represent a significant advancement in addressing the limitations of conventional stenting methods, potentially revolutionizing patient care in this field.

However, repairs performed by a nonspecialized hepatopancreatobiliary team frequently lead to results that are less than ideal[3]. Patients with hepaticojejunostomy strictures commonly present with recurrent cholangitis, occasionally accompanied by jaundice. Laboratory findings often reveal elevated levels of alkaline phosphatase and leukocytosis. Although ultrasound can detect intrahepatic bile duct dilation in 50% of cases, magnetic resonance cholangiopancreatography (MRCP) provides more precise imaging of strictures. However, in patients with nondilated bile ducts, factors such as pneumobilia and nearby intestinal loops, can obscure the diagnosis[4].

Antibiotics and percutaneous biliary drainage, which also validate the diagnosis of anastomotic stricture, are commonly used to treat cholangitis in these patients. Unless there are significant structural flaws, high-pressure balloon dilatation is performed only after resolution of the infection. Although this technique has long-term success rates of 45%-71%, recurrence rates remain high and require repeated interventions in approximately 30%-40% of patients[5]. Biliary injuries are classified into three categories: Peripheral leaks, central leaks, and biliary strictures. Various categories, including McHanon, Strasberg, and Bismuth, had also been used. The type and timing of diagnosis determine the complexity of treatment[6]. A viable substitute that offers similar or better patency without requiring stent removal is biodegradable stents. In fact, preliminary clinical data have shown that these stents were safe and practical and had long-term efficacy[7].

CASE PRESENTATION

Chief complaints

A 39-year-old woman underwent laparoscopic cholecystectomy (LC), which was complicated by proximal bile duct injury (BDI). Subsequently, she experienced recurrent episodes of cholangitis. She has been presenting to the hospital with typical symptoms of cholangitis, mainly abdominal pain and tenderness.

History of present illness

In 2018, she underwent hepaticojejunostomy biliary reconstruction, followed by prolonged T-tube drainage. Despite these interventions, the patient continued to experience multiple episodes of hepatic cholangitis, which were managed with repeated antibiotic courses and frequent hospital admissions. In December 2021, MRCP revealed postcholecystectomy biliary stasis, with dilation of the intrahepatic biliary radicals and a possible stricture at the hepaticojejunostomy site. A follow-up MRCP in October 2022 revealed further hepatic duct dilation and multiple filling defects in the common hepatic duct, suggesting stricture formation and obstruction at the hepaticojejunostomy site. Then the patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) with cholangioscopy which confirmed the MRCP findings (Video 1). Immediate percutaneous transhepatic cholangiography (PTC) confirmed the diagnosis (Figure 1A) and facilitated placement of a 12-Fr internal/external biliary drain (Cook). Follow-up magnetic resonance imaging in October 2023 showed normal biliary drainage with minimal dilation of the biliary ducts and evidence of pneumobilia, suggesting a functioning biliary drain. Subsequent PTC revealed an ongoing 3-cm hepaticojejunostomy site stricture, which required balloon dilation up to 12 mm and persistent mid-balloon wasting (Figure 1B). A 12-Fr internal/external biliary drain (Cook) was then inserted for internal drainage.

Figure 1 Biliary stricture treatment procedures shown. A: Percutaneous transhepatic cholangiography shows the stricture; B: Balloon dilation up to 12 mm in the stricture; C: Biliary stent insertion using three radiopaque markers with excellent follow.

In March 2024, another elective PTC showed with stricture, for which balloon dilatation using controlled radial expansion up to 10 mm was performed; once again, mid-balloon wasting persisted, suggesting refractory stricture. During the same session, percutaneous transhepatic cholangioscopy vein TY-ISS-L370 was performed to extract intrahepatic lithiasis using a push technique (video documentation available). Subsequently, a new 12-Fr internal/external biliary drain (Cook) was inserted to maximize internal drainage.

In August 2024, the patient underwent another PTC with anterograde biodegradable biliary stent insertion using three radiopaque markers at the proximal, middle, and distal portions of the biodegradable 11.8-Fr, 6-cm-long stent (SX/ELLA stent DV) (Figure 1C). To maximize stent drainage, in-stent balloon dilatation up to 6 mm was performed. Thereafter, anterograde diagnostic cholangiogram showed free flow of contrast through the stent lumen into the jejunal loops. Fluoroscopy confirmed satisfactory stent position. Since the first PTC intervention, the patient has had no documented hospital admission for cholangitis and achieved remarkable improvements in liver function tests (Table 1). She remained clinically and biochemically stable for 5 months after biodegradable biliary stenting. She will be followed-up during clinic visits and with blood testing every 3 months.

Table 1 Trend of liver enzymes from early intervention to the latest follow-up.

Liver function test	Reference range/unit	October 9, 2024	October 22, 2022
Total bilirubin	< 21.0 μmol/L	7.68	11.34
Direct bilirubin	≤ 5.0 μmol/L	3.76	6.68
Alkaline phosphatase	35-104 U/L	169	366.92
Alanine aminotransferase	< 35 U/L	61.40	19.39
Aspartate aminotransferase	< 35 U/L	41.50	23.65
Albumin	35.0-52.0 g/L	41.80	24.04
Protein	64-83 g/L	82.100	77.08

History of past illness

LC.

Personal and family history

No family history of similar condition and no other personal history.

Physical examination

Physical examination was unremarkable except for mild abdominal tenderness. Vital signs were all normal throughout.

Laboratory examinations

Table 1 shows laboratory examinations.

Imaging examinations

In December 2021 MRCP: Postcholecystectomy biliary stasis, dilation of intrahepatic biliary radicals, possible stricture at the hepaticojejunostomy site. In October 2022 MRCP: Further hepatic duct dilation, multiple filling defects in the common hepatic duct, stricture formation and obstruction at the hepaticojejunostomy site. In October 2022 PTC: Confirmed diagnosis of stricture at hepaticojejunostomy site. In October 2023 magnetic resonance imaging: Normal biliary drainage, minimal dilation of biliary ducts, evidence of pneumobilia. In October 2023 PTC: Ongoing 3-cm hepaticojejunostomy site stricture, mid-balloon wasting during balloon dilation. In March 2024 PTC: Persistent stricture, mid-balloon wasting during balloon dilation. In August 2024 PTC: Successful placement of biodegradable biliary stent, free flow of contrast through stent lumen into jejunal loops.

FINAL DIAGNOSIS

Recurrent biliary stricture secondary to proximal BDI.

TREATMENT

Hepaticojejunostomy, repeated PTC with balloon dilatation, and ultimately biodegradable biliary stenting.

OUTCOME AND FOLLOW-UP

Complete drainage of the biliary system. Long-term follow-up with regular imaging and blood tests is essential to monitor for stricture recurrence and ensure treatment effectiveness.

DISCUSSION

This case clearly highlighted the complexities and challenges of managing a patient who developed a series of biliary complications after cholecystectomy. Despite multiple biliary interventions, our patient required biliary stenting to increase the chance of stricture remodeling. These complications can result in medical and financial burden to patients and healthcare providers. In this case, ERCP proved superior to PTC as a first-line approach due to its less invasive nature and ability to provide both diagnostic and therapeutic interventions in a single procedure. The successful use of ERCP for biliary drainage and stent placement demonstrated its efficacy in managing complex biliary strictures, avoiding the need for more invasive percutaneous techniques initially.

Advancements in laparoscopic surgical techniques and equipment have led to the use of LC as the preferred surgical technique for gallbladder removal. However, the increasing number of reported BDI as a complication of LC has become a major concern. Although a rare complication, BDI has been well documented to have incidence rates of 0.37% in Belgium, 0.42% in Italy, and 1.12% in China[8]. BDIs can significantly alter the postsurgical course and potentially lead to bile leak, bile duct stricture, and chronic cholangitis. Therefore, BDIs are linked to morbidity, mortality, and a significant financial burden on healthcare systems[9].

The postoperative management of BDI includes antibiotic prophylaxis for acute cholangitis, especially in the setting of predictable incomplete drainage. Management decisions can vary depending on the extent of BDI. In our patient, surgical treatment was chosen, because the bile duct continuity was completely destroyed. In particular, to restore biliary drainage, we performed hepaticojejunostomy, which is often necessary in patients with major BDI[10]. T-tube placement after hepaticojejunostomy is recommended to allow continuous drainage and monitoring, but this may lead to complications, such as infection and obstruction[11]. In this patient, the frequent antibiotic treatments for recurring cholangitis and multiple hospitalizations demonstrated the difficulty of long-term management of complex biliary injuries.

This case highlighted several key considerations for treating patients with biliary complications after cholecystectomy. To identify and treat recurrent strictures and cholangitis, careful follow-up is essential. This patient required a range of interventions, from biliary drainage to refined endoscopic procedures; this highlighted the fact that multidisciplinary care involving gastroenterologists, interventional radiologists, and surgeons is crucial to optimize outcomes[10]. Moreover, as major improvements in the treatment of complicated biliary disorders, sophisticated imaging and minimally invasive procedures, such as biodegradable stenting and cholangioscopy, were performed on this patient. More clinical trials are required to evaluate the safety and efficacy of biodegradable stents in treating refractory biliary strictures. Furthermore, the persistence of the stricture despite several treatment modalities raised the likely need for even more creative methods, such as novel stent designs or therapeutic approaches, in the future. Regardless of the clinical results of biodegradable biliary stenting, patients should be offered long-term follow-up to ascertain the rates of real stricture remodeling and recurrence.

CONCLUSION

This case demonstrated how strictures and recurrent cholangitis complicate the management of BDIs after LC. A customized and multidisciplinary approach to control chronic biliary disease was proven effective, as shown by the patient’s good outcome. This was achieved by integrating balloon dilatation sessions, biliary drainage, stone clearing, and biodegradable stent placement. Long-term follow-up and continued monitoring remain essential to ensure patient stability and prevent further complications.