PTCD-Assisted ERCP for Severe Stricture at the Biliary-enteric Anastomosis following Pancreaticoduodenectomy: A Case Report

Introduction: Post-pancreaticoduodenectomy biliary-enteric anastomosis stenosis (BEAS) poses substantial therapeutic challenges secondary to surgically altered anatomy. Conventional endoscopic interventions are frequently unsuccessful in patients with both altered gastrointestinal anatomy and severe fibrotic strictures. This study reports the utilization of a combined percutaneous transhepatic cholangiodrainage (PTCD) and endoscopic retrograde cholangiopancreatography (ERCP) rendezvous technique, incorporating an innovative mechanical dilation method using a stent retriever, for the management of refractory BEAS. Case Presentation: A 50-year-old male who had undergone pancreaticoduodenectomy (PD) developed recurrent cholangitis due to BEAS, which was confirmed by magnetic resonance cholangiopancreatography (MRCP). Previous attempts to access the anastomosis via conventional ERCP and to dilate the stricture using a standard PTCD-based approach were unsuccessful. Consequently, a novel hybrid approach that utilized both PTCD for access and endoscopic therapy for treatment was employed. The procedure involved advancing a guidewire through the PTCD tract into the jejunal lumen under fluoroscopic guidance, which was then endoscopically retrieved using foreign body forceps. Bidirectional traction stabilized the access route, enabling gastroscopic navigation to the anastomosis. For the refractory stenosis, controlled mechanical dilation was performed using a stent retriever for rotational drilling, followed by balloon dilation and placement of a nasobiliary catheter. Conclusions: This hybrid approach integrates percutaneous and endoscopic modalities to overcome anatomical barriers in complex BEAS. The innovative use of a stent retrieval device for controlled mechanical dilation provides a salvage option when standard devices fail. This strategy demonstrates technical feasibility and efficacy for refractory BEAS, expanding therapeutic possibilities in challenging post-surgical anatomy.