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A 53-year-old man was referred to our clinic with the problem of continuous bile drainage (approximately 200mL bile per day) that was still occurring 10 days after an intra-abdominal drain had been placed into the operation area following a laparoscopic cholecystectomy. At endoscopic retrograde cholangiography (ERC), a stone was detected at the distal site of the common bile duct (CBD), sphincterotomy was performed, and the stone was extracted via balloon. During ERC, injection of contrast medium together with balloon occlusion revealed the presence of a leak from the cystic stump at the level of the percutaneous drain (●" Fig.1a). Surprisingly, the endoscopist also noticed that intrahepatic ducts in a segment of the right posterior hepatic lobe were not filled during balloon occlusion cholangiogram (●" Fig.1a). Suspecting both aberrant bile duct injury and cystic stump leakage, we planned contrast injection via a percutaneous drain. The right posterior intrahepatic ducts, which ran to the cystic stump, were filled retrogradely with contrast medium (●" Fig.1b). Unfortunately, a guidewire could not be passed into the hepatic duct although several attempts were made. A 7-Fr nasobiliary drain was placed through the CBD. On a subsequent percutaneous transhepatic cholangiogram, slightly dilated right posterior intrahepatic bile ducts were visualized. The posterior right hepatic duct was seen to communicate with the cystic duct stump, fromwhich contrast medium was leaking into the intra-abdominal space (●" Fig.1c). A guidewire introduced via percutaneous access into the duodenum was then caught by a snare using a rendezvous technique and was eventually passed all the way to the patient’s mouth to provide through-and-through access. Using this guidewire, a 10-Fr bili-

Endoscopic treatment of a cystic duct stump leak complicated by aberrant bile duct communication