# Novel Biliary Stent Insertion via Percutaneous Trans-jejunal Approach for Liver Remnant Preservation After Extended Right Hepatectomy

## TL;DR

A new method of inserting a biliary stent through the jejunum successfully restored bile drainage after a complex liver surgery complication.

## Contribution

A novel percutaneous trans-jejunal stent insertion technique is introduced for treating postoperative biliary strictures after extended right hepatectomy.

## Key findings

- Traditional percutaneous transhepatic drainage failed in a patient with a severe anastomotic stricture.
- A metal stent inserted via a jejunal puncture successfully restored bilio-enteric drainage.
- The novel radiological intervention salvaged liver function when standard approaches were ineffective.

## Abstract

Extended right hepatectomy (ERH) for hilar cholangiocarcinoma (HCCA) is a complex procedure associated with a high risk of postoperative complications. We present a case of ERH complicated by a biliary fistula at the hepatico-jejunostomy site, which led to a severe anastomotic stricture. Traditional percutaneous transhepatic drainage repeatedly failed in this case. The stricture was ultimately treated with trans-jejunal metal stent insertion, successfully restoring bilio-enteric drainage.

A 62-year-old male patient was diagnosed with HCCA. After staging, he underwent liver vein deprivation to augment the future liver remnant (FLR), followed by curative resection via ERH (segments I and IV-VIII). Postoperatively, a bile leak at the anastomotic site resulted in a bilio-cutaneous fistula. While conservative management led to a gradual resolution, the fistula caused a tight anastomotic stricture, leading to obstructive jaundice. Traditional percutaneous transhepatic drainage attempts repeatedly failed to traverse the lengthy stricture. Consequently, a novel procedure of inserting a metal biliary stent via a percutaneous puncture of the jejunal loop was attempted.

Under CT guidance, the Roux loop was catheterized and distended with contrast, and a guidewire was positioned inside. The patient was then transferred to the angiography suite. Under fluoroscopy, a transjugular intrahepatic portosystemic shunt needle punctured the bile duct stump, providing access to the Roux loop. A fully covered metal stent was successfully deployed crossing the anastomosis re-establishing bilio-enteric drainage. This novel radiological intervention salvaged the remnant liver when standard approaches had failed.

Hepatico-jejunostomy stricture following ERH is a critical postoperative complication that can severely compromise FLR function. Surgical options in such cases are limited and pose significant risks. Radiological intervention offers a promising alternative, enabling effective drainage even in the most challenging postoperative scenarios.