Balloon-Assisted Redirection: A Novel Endoscopic Technique for Complex Biliary Injury Post-Cholecystectomy

Case A 52-year-old female presented with abdominal pain, nausea, and persistent bilious drainage (200–300 mL/day) for 30 days following open cholecystectomy. Three months earlier, she had biliary pancreatitis and choledocholithiasis, managed by endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and placement of a 10 Fr × 7 Cm biliary plastic stent. After symptomatic improvement, she underwent elective cholecystectomy at an outside hospital, which was converted into an open procedure due to dense adhesions, and a drain was placed in the gallbladder fossa. Postoperatively, she continued to have high-output bilious drainage without jaundice. A repeat ERCP elsewhere showed stent migration, a tight common hepatic duct (CHD) proximal CBD stricture, and failure to access the upstream duct. She was referred to our center. On admission, she was afebrile but nutritionally depleted. Magnetic resonance cholangiopancreatography revealed a 23-mm-long CHD-proximal CBD stricture and peri-cholecystic collection. Given the ongoing bile leak and poor surgical fitness, repeat ERCP was planned. Cholangiogram showed extravasation of contrast from the proximal CBD with a cutoff at the CHD site. The guidewire repeatedly entered into the leak site during ERCP. To prevent the entry of the guidewire into the leak, a novel “balloon-assisted redirection” technique was employed. A 0.025 guidewire (VisiGlide, Olympus, Tokyo, Japan) was passed through a percutaneous drain, followed by a biliary balloon catheter (Extractor, Boston Scientific, Massachusetts, United States). A balloon was positioned at the leak site and inflated (to 10 mm), which enabled the successful entry of the guidewire into the upstream duct. Both right and left ducts were opacified, and two biliary plastic stents were placed ([ Fig. 1A–D ]; [ Video 1 ]). Bile output reduced to