Endoscopic ultrasound-guided hepaticojejunostomy using forward-viewing echoendoscope for transected aberrant right posterior hepatic duct in Roux-en-Y hepaticojejunostomy

An aberrant right posterior hepatic duct is one of the most common risk factors for bile duct injury during surgical procedures. Complete transection of the bile duct necessitates surgical repair. Recently, endoscopic ultrasound (EUS)-guided hepaticojejunostomy using a forwardviewing echoendoscope to manage complete biliary obstruction in patients with surgically altered anatomy has been reported [1–4]. Although most of the reports described complete stenosis of hepaticojejunostomy anastomoses with pancreaticoduodenectomy and modified Child reconstruction, none has documented repairing a completely transected bile duct with Roux-en-Y hepaticojejunostomy. A 72-year-old woman who underwent total pancreatectomy with Roux-en-Y hepaticojejunostomy for intraductal papillary mucinous carcinoma 2 months prior presented with abdominal pain. Abdominal computed tomography showed dilatation of the right posterior hepatic duct and small abscesses (▶Fig. 1). A retrospective imaging review of the patient’s preoperative magnetic resonance images revealed an aberrant right posterior hepatic duct (▶Fig. 2). Complete transection and ligation of the aberrant duct during the previous operation were suspected (Strasberg classification type B) [5]. We considered performing an EUS-guided hepaticojejunostomy using the forward-viewing echoendoscope (TGFUC260J; Olympus Medical Systems, Tokyo, Japan). However, we assumed that insertion into the bilioenteric limb around the anastomosis would be challenging owing to the Roux-en-Y reconstruction; thus, we initially performed balloon enteroscopy (SIF-290H; Olympus Medical Systems, Tokyo, Japan) to confirm the direction of the anastomosis. E-Videos