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A 64-year-old womanwho had previously undergone a Roux-en-Y hepaticojejunostomy because of iatrogenic bile duct injury during cholecystectomy, presented recurrent episodes of cholangitis due to a stenosis of the hepaticojejunostomy. A percutaneous transhepatic cholangiography with biliary dilation and plastic stenting of the biliodigestive anastomosis was performed. After a successful left duct approach, accidental laceration of the right biliary duct occurred. Percutaneous stenting was impossible because the guidewire repeatedly looped through the laceration. The patient was referred for single-balloon enteroscopy (SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP). The enteroscope (SIF-Q180; Olympus Medical Systems, Tokyo, Japan) was advanced into the jejunum and the afferent limbwas intubated. The hepaticojejunostomy was identified, with visualization of the left duct plastic stent and the guidewire that had been placed percutaneously (●" Fig.1). Cholangiography confirmed a right duct biliary leak (●" Fig.2), and guidewire looping (●" Fig.3) near the biliodigestive anastomosis. In a combined endoscopic and percutaneous rendezvous procedure, the guidewire was straightened and a 7-Fr plastic stent (3 cm; Olympus, Japan) was placed endoscopically (●" Fig.4) through the hepaticojejunostomy, excluding the biliary duct laceration (●" Fig.4 and●" Fig.5). SBE-ERCP was subsequently repeated, with biliary stent removal through the overtube. Cholangiography revealed no biliary leak or anastomotic stricture (●" Fig.6). Iatrogenic biliary duct injuries are serious conditions, for which endoscopic stenting treatment has gained increasing potential. For patients with complex post-surgical anatomy, SBE for ERCP is a safe and Fig.1 Enteroscopic view of the biliodigestive anastomosis, in a 64-year-old woman with a history of Roux-en-Y hepaticojejunostomy, performed because of iatrogenic bile duct injury during cholecystectomy. She had recurrent episodes of cholangitis because of stricture of the hepaticojejunostomy and so dilation and plastic stenting of the left bile duct was done, but there was accidental injury to the right biliary duct. The percutaneously placed left duct stent and guidewire can be seen. The guidewire is exiting the right duct. Fig.2 Contrast injection into the biliary system showing biliary leakage in the right duct, near the biliodigestive anastomosis.

Iatrogenic biliary injury in a patient with Roux-en-Y hepaticojejunostomy: stenting repair with single-balloon enteroscopy-assisted ERCP