ESD-Assisted Recanalization of a Buried Hepaticojejunostomy

ESD-assisted recanalization of a buried hepaticojejunostomy when ESD skills save an ERCP case. Completely epithelialized hepaticojejunostomy. No orifice. Just a tiny bile leak. ESD mucosal dissection. Exposed fibrotic plate. Needle-knife recanalization. Balloon dilation + 4 stents. Sometimes ESD techniques unlock impossible ERCP cases. A 55-year-old woman presented 8 months after pancreaticoduodenectomy with a hepaticojejunostomy stricture complicated by a biliary cutaneous fistula following loss of a percutaneous biliary drain. During enteroscopy, the hepaticojejunostomy appeared completely epithelialized with no visible orifice. The only clue was a tiny point of bile leakage on the jejunal mucosa. Conventional cannulation failed. The turning point of the procedure was the use of an ESD knife to dissect the mucosal layer, exposing the fibrotic anastomotic plate buried beneath the regenerated epithelium. Once the fibrotic layer was identified, a needle-knife stricturotomy allowed access to the hepatic duct. The tract was then dilated to 10 mm, and four plastic stents were placed.This ESD-assisted approach enabled successful recanalization of a completely epithelialized hepaticojejunostomy, restoring internal biliary drainage and converting the external biliary fistula. A good reminder that advanced endoscopic dissection techniques can solve complex post-surgical biliary problems and avoid more invasive interventions.