International Journal of Gastrointestinal Intervention journal homepage: www.ijgii.org Int J Gastrointest Interv 2019;8:41–44 Case Report Percutaneous-transhepatic creation of a bilioenteric neoanastomosis in a patient with bile duct injury using cone-beam computed tomography Nathan Wnuk 1, *, Ana Maria Pabon-Martinez 1 , Armeen Mahvash 2 , Gouthami Chintalapani 3 , Thomas A. Aloia 4 , and Bruno C. Odisio 2 A B S T R A C T We describe the creation of a percutaneous transhepatic bilioenteric neoanastomosis with the aid of cone-beam computed tomography (CBCT) in a patient suffering from a complicated bile leak after extensive hepatobiliary surgery. Access to the afferent bowel limb was safely performed in a single-stick manner via transhepatic approach with the aid of real-time navigation fluoroscopic imaging generated by CBCT arteriography. CBCT confirmed access of the afferent limb and absence of peri-anastomotic vessel damage, allowing the successful creation of a bilioenteric neoanasto- mosis, resolving the patient’s biliary leak. The patient is alive and asymptomatic at 12-month follow-up, demonstrating patency of the percutaneous bilioenteric neoanastomosis. Copyright © 2019, Society of Gastrointestinal Intervention. Keywords: Biliary intervention; Bilioenteric neoanastomosis; Cone-beam computed tomography; Fusion imaging; Percutaneous intervention 1 MD Anderson Cancer Center, Houston, TX, USA 2 Department of Vascular and Interventional Radiology, MD Anderson Cancer Center, Houston, TX, USA 3 Siemens Medical Solutions USA Inc., Hoffman Estates, IL, USA 4 Department of Surgical Oncology, Division of Surgery, MD Anderson Cancer Center, Houston, TX, USA Received October 4, 2018; Revised December 30, 2018; Accepted December 30, 2018 * Corresponding author. MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA. E-mail address: nathan.wnuk@gmail.com (N. Wnuk). ORCID: https://orcid.org/0000-0002-2720-0120 pISSN 2636-0004 eISSN 2636-0012 https://doi.org/10.18528/ijgii180037 This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction Herein, we describe the creation of a percutaneous transhe- patic bilioenteric neoanastomosis adjacent to the native surgical hepaticojejunostomy with the aid of cone-beam computed to- mography (CBCT) for procedure planning and real-time imaging guidance on a patient with an aberrant isolated right posterior bile duct injury following extensive hepatobiliary surgery. Case Report All procedures performed in studies involving human partici- pants were in accordance with the ethical standards of the insti- tutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethi- cal standards. Informed consent was waived by our Institutional Review Board. Patient This case report was compliant with the Health Insurance Por- tability and Accountability Act and approved by our institutional review board with a waiver of informed consent. A 19-year-old female patient with Von Hippel–Lindau syndrome, pancreatic neuroendocrine tumor metastatic to the liver and skip metas- tasis to the bile ducts underwent a left hepatectomy, pylorus- preserving pancreaticoduodenectomy, duodenojejunostomy, and hepaticojejunostomy. Immediate postoperative course was remarkable for biloma formation arising from the excluded right posterior bile ducts (Fig. 1), which was addressed with percutane- ous abscess drain placement within the biloma and placement of a percutaneous transhepatic external biliary drain. After multidis- ciplinary discussion, the decision was made to attempt creation of a percutaneous bilioenteric neoanastomosis between the aberrant posterior bile duct and the afferent bowel limb.