Biliary leaks: treatment by means of percutaneous transhepatic biliary drainage

PURPOSE: To evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks. MATERIALS AND METHODS: Sixteen patients with a biliary leak involving either the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2) were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to severe acute necrotizing pancreatitis in six patients, while 10 patients had postoperative leak. Percutaneous transhepatic biliary drainage was performed with a 12-F catheter, with two series of side holes positioned on both sides of the extravasation to divert bile flow away from the defect. RESULTS: In 13 patients, the biliary leak healed after drainage (mean duration, 78 days). In four of these patients, a slight residual narrowing of the bile duct was treated by means of either balloon dilation (n = 2) or balloon dilation followed by insertion of a metallic stent (n = 2). All 13 patients remained cured (mean follow-up, 38 months). Two patients with severe acute necrotizing pancreatitis died of complications unrelated to the biliary leak. Vascular complications occurred in two patients, one of whom died after surgical drainage of a subcapsular hematoma. CONCLUSION: Biliary leaks can be treated successfully by means of percutaneous transhepatic biliary drainage. The procedure is particularly useful when surgical or endoscopic management has failed.     

Isolated Right Segmental Hepatic Duct Injury Following Laparoscopic Cholecystectomy

Purpose Laparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. There is an increased incidence of bile duct injuries in LC compared with the open technique. Isolated right segmental hepatic duct injury (IRSHDI) represents a challenge not only for management but also for diagnosis. We present our experience in the management of IRSHDI, with long-term follow-up after treatment by a multidisciplinary approach.Methods Twelve consecutive patients (9 women, mean age 48 years) were identified as having IRSHDI. Patients demographics, clinical presentation, management and outcome were collected for analysis. The mean follow-up was 44 months (range 2–90 months).Results Three patients had the LC immediately converted to open surgery without repair of the biliary injury before referral. Treatments before referral included endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage and surgery, isolated or in combination. The median interval from LC to referral was 32 days. Eleven patients presented with biliary leak and biloma, one with obstruction of an isolated right hepatic segment. Post-referral management of the biliary lesion used a combination of ERCP stenting, percutaneous drainage and stent placement and surgery. In 6 of 12 patients ERCP was the first procedure, and in only one case was IRSHDI identified. In 6 patients, percutaneous transhepatic cholangiography (PTC) was performed first and an isolated right hepatic segment was demonstrated in all. The final treatment modality was endoscopic management and/or percutaneous drainage and stenting in 6 patients, and surgery in 6. The mean follow-up was 44 months. No mortality or significant morbidity was observed.Conclusion Successful management of IRSHDI after LC requires adequate identification of the lesion, and multidisciplinary treatment is necessary. Half of the patients can be treated successfully by nonsurgical procedures.     

Percutaneous transhepatic biliary drainage

Over the past three decades, endoscopic and percutaneous biliary drainage have become readily available in most hospital settings and these minimally invasive techniques have revolutionized the treatment of patients with biliary obstruction. In the past, treatment of biliary obstruction had required surgery under general anesthesia and an extended hospital stay. Currently, the same patient can most often be treated either endoscopically as an outpatient or during a short hospital stay after percutaneous drainage under moderate sedation. This article reviews the indications and technique of percutaneous transhepatic cholangiography and biliary drainage.     

Treatment of biliary leaks and fistulae by simultaneous percutaneous drainage and diversion

Although biliary fistulae and bilomas are often adequately managed with percutaneous drainage, persistent bile duct leaks are difficult to control. The primary surgical goal in this situation is to decompress the biliary system through diversion of bile flow to facilitate healing of the defect in the bile ducts. We report 3 patients with large biliary duct defects who underwent percutaneous transhepatic cholangiography which demonstrated the site of the biliary leakage. Then, extrapolating the aforementioned surgical tenet to these patients, all 3 were successfully treated with interventional radiologic techniques: simultaneous percutaneous transhepatic biliary diversion to control biliary flow and percutaneous biloma drainage to facilitate closure of the cavity.     

Biliary pressure: manometric and perfusion studies at percutaneous transhepatic cholangiography and percutaneous biliary drainage

Manometric pressure recordings were attempted during percutaneous transhepatic cholangiography (PTC) and after percutaneous biliary drainage (PBD) in 203 cases. Successful readings were achieved at PTC in 85% (104/122) of patients. Pressure measurements were also obtained through 56 biliary drainage catheters, and controlled perfusion challenges were performed in 12 patients (on 18 occasions). Documentation of the occasionally poor correlation between the caliber of ducts and the degree of obstruction (i.e., pressure) was shown, and it was suggested that very high pressures may be predictive of a bile leak after PTC. Adequacy of percutaneous drainage and stricture dilatation were further assessed with these manometric techniques. Pressure and perfusion data aided in detecting and determining the significance of the nondilated obstructed duct, the dilated nonobstructed ductal system, and subtle distal ductal strictures. The knowledge obtained from percutaneous pressure recordings may help to determine appropriate therapy.     

Percutaneous transhepatic biliary drainage for bile leaks and fistulas

Percutaneous transhepatic cholangiography and biliary drainage were performed in 12 patients with major injuries to the bile ducts manifested by biliary leaks and fistulas. Eleven of the 12 patients had had inadvertent biliary trauma during surgery. In six patients, the biliary leaks sealed with percutaneous drainage. In other patients requiring definitive surgical procedures on the biliary tract, initial percutaneous drainage allowed these procedures to be delayed until the patients' clinical condition improved. Percutaneous biliary drainage is an important adjunct to the management of patients with traumatic extravasation of bile into the peritoneal cavity or biliary-cutaneous fistula.     

Non-surgical palliative treatment of patients with malignant biliary obstruction--the place of endoscopic and percutaneous drainage

Non-surgical methods to treat patients with inoperable malignant biliary obstruction are endoscopic retrograde biliary drainage and ultrasound guided percutaneous transhepatic biliary drainage. During a 2 year evaluation a total of 144 patients were admitted with malignant biliary obstruction: 93 with a mid- or distal common bile duct stenosis; 51 patients with a perihilar stenosis. Endoscopic biliary drainage was performed in 123 patients and ultrasound guided percutaneous biliary drainage in 57 patients. An effect on jaundice was seen in more patients after percutaneous biliary drainage (91%) than with endoscopic biliary drainage (70%). However with the percutaneous method only 63% of patients were drained internally. The site of the stenosis seemed to be an important factor. In patients with perihilar obstruction early complications after endoscopic biliary drainage occurred in 41% of drained patients compared with 3% procedure-related and 28% catheter-related complications with ultrasound guided drainage. A major complication of the endoscopic method in perihilar disease was cholangitis due to inadequate drainage.     

Refractory biliary leak from intrahepatic biliary-enteric anastomosis treated by selective portal vein embolization

A 66-year-old woman underwent partial hepatectomy and pylorus-preserving pancreaticoduodenectomy for advanced Klatskin-type cholangiocarcinoma, and five intrahepatic biliary-enteric anastomoses were created. One anastomosis between the anterior-superior segmental bile duct and the jejunum developed a refractory biliary leak. Selective portal venous embolization with use of ethanol was performed in the anterior-superior portal branch to eliminate the production of bile by the target segment. The patient's clinical course was uneventful and the leak resolved after portal vein embolization.     

Management of post-surgical biliary leakage with percutaneous transhepatic biliary drainage (PTBD) and occlusion balloon (OB) in patients without dilatation of the biliary tree: preliminary results

Objective  

To compare the outcome of patients affected by biliary leak after major biliary surgery and treated with percutaneous transhepatic biliary drainage (PTBD) alone with that of similar patients treated with PTBD and concurrent positioning of an occlusion balloon (PTBD-OB).     

Percutaneous Biliary Interventions: Inside and Outside the Box: The Role of the Interventional Radiologist in Bile Leak Diagnosis and Management

Bile leaks are rare but potentially devastating iatrogenic or posttraumatic complications. This is being diagnosed more frequently since the advent of laparoscopic cholecystectomy and propensity toward nonsurgical management in select trauma patients. Timely recognition and accurate characterization of a bile leak is crucial for favorable patient outcomes and involves a multimodal imaging approach. Management is driven by the type and extent of the biliary injury and requires multidisciplinary cooperation between interventional radiologists, endoscopists, and hepatobiliary/transplant surgeons. Interventional radiologists have a vital role in both the diagnosis and management of bile leaks. Percutaneous interventional procedures aid in the characterization of a bile leak and in its initial management via drainage of fluid collections. Most bile leaks resolve with decompression of the biliary system which is routinely done via endoscopic retrograde cholangiopancreaticography. Some bile leaks can be definitively treated percutaneously while others necessitate surgical repair. The primary principle of percutaneous management is flow diversion away from the site of a leak with the placement of transhepatic biliary drainage catheters. While this can be accomplished with relative ease in some cases, others call for more advanced techniques. Bile duct embolization or sclerosis may also be required in cases where a leaking bile duct is isolated from the main biliary tree.     

Pediatric biliary interventions

The most common indication for percutaneous biliary evaluation and intervention in children is for the diagnosis and treatment of liver transplant complications, including strictures and bile leaks. Because liver transplants in children are commonly performed using a Roux-en-Y biliary-enteric anastomosis, endoscopic retrograde cholangiopancreatography is not technically possible; therefore, the first-line procedure for evaluation and treatment of biliary obstruction in this population is percutaneous transhepatic cholangiography (PTC). Percutaneous biliary intervention can be challenging in these patients, because ductal dilation may be minimal or altogether absent in pediatric transplant livers even in the setting of severe obstruction. However, with proper technique, including the use of ultrasound guidance, technical success rates for PTC and biliary drainage can be similar to those in adults. Biliary drainage and biliary stenosis management is a long-term commitment that usually takes several months to more than a year and may require multiple repeat cholangioplasties and biliary drainage catheter exchanges. Due to its minimally invasive nature and relatively low morbidity and mortality compared with open surgical alternatives, percutaneous biliary intervention should be considered the first-line treatment option in children with biliary stenosis who have had previous liver transplant, and for those nontransplant patients who cannot be treated endoscopically.     

原位肝移植术后胆道狭窄的介入治疗

目的:探讨经T型管及其窦道和经皮肝穿刺胆道引流治疗原位肝移植术后胆道狭窄的可行性及其疗效.方法:对252例原位肝移植术后出现胆道狭窄的26例患者分别行胆道气囊扩张术、胆道引流术和胆道支架置入术.结果:3例胆道狭窄合并胆瘘患者和3例单纯吻合口狭窄患者,经气囊扩张术和胆道引流后痊愈.6例肝内外胆管多发狭窄患者,气囊反复扩张胆道狭窄段后,5例狭窄纠正而获得痊愈;1例气囊扩张治疗后出现肝内血肿,再次行肝移植.12例肝内外胆管多发狭窄合并胆泥的患者,经反复球囊导管扩张后,10例狭窄明显减轻,黄疸缓解;1例置入胆道支架,后因支架管阻塞而再次肝移植;1例治疗后狭窄仍存在,黄疸无缓解而再次肝移植.2例T型管引流口段狭窄行经皮肝穿刺胆道引流术后,狭窄明显减轻,黄疸缓解.结论:经T型管及其窦道和经皮肝穿刺胆道引流是治疗原位肝移植术后胆道狭窄的良好方法.     

Percutaneous Transhepatic Biliary Drainage in the Management of Postsurgical Biliary Leaks in Patients with Nondilated Intrahepatic Bile Ducts

Purpose To assess the feasibility of percutaneous transhepatic biliary drainage (PTBD) for the treatment of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts, its efficacy in restoring the integrity of bile ducts, and technical procedures to reduce morbidity. Methods Seventeen patients out of 936 undergoing PTBD over a 20-year period had a noncholestatic liver and were retrospectively reviewed. All patients underwent surgery for cancer and suffered a postsurgical biliary leak of 345 ml/day on average; 71% were in poor condition and required permanent nutritional support. An endoscopic approach failed or was excluded due to inaccessibility of the bile ducts. Results Established biliary leaks and site of origin were diagnosed an average of 21 days (range 1–90 days) after surgery. In all cases percutaneous access to the biliary tree was achieved. An external (preleakage) drain was applied in 7 cases, 9 patients had an external–internal fistula bridging catheter, and 1 patient had a percutaneous hepatogastrostomy. Fistulas healed in an average of 31 days (range 3–118 days ) in 15 of 17 patients (88%) following PTBD. No major complications occurred after drainage. Post-PTBD cholangitis was observed in 6 of 17 patients (35%) and was related to biliary sludge formation occurring mostly when drainage lasted >30 days and was of the external–internal type. Median patient survival was 17.7 months and in all cases the repaired biliary leaks remained healed. Conclusions PTBD is a feasible, effective, and safe procedure for the treatment of postsurgical biliary leaks. It is therefore a reliable alternative to surgical repair, which entails longer hospitalization and higher costs.     

Endoscopic approach to malignant biliary obstruction

A consensus is growing among units that have experience in both endoscopic and percutaneous stenting techniques that the endoscopic approach to malignant biliary strictures is more comfortable for the patient and has fewer complications. This article describes endoscopic biliary drainage in malignant stenoses of the bile ducts and delineates the respective indications for percutaneous and endoscopic techniques. New materials have become available for endoscopic and percutaneous biliary drainage, particularly metallic stents which may provide better palliation.     

Biliary duct ablation with N-butyl cyanoacrylate

PURPOSE: To assess the efficacy of percutaneous insertion of n-butyl cyanoacrylate (NBCA) in the ablation of bile ducts in patients with persistent postsurgical bile leaks in which traditional means of treatment have failed. MATERIALS AND METHODS: Ablation of bile ducts with NBCA was performed in six patients (two men and four women). The average length of follow-up was 27 months (range, 13-46 months). Four patients presented after hepatic lobectomy with a persistent bile leak, one patient presented after cholecystectomy with a chronically obstructed bile duct, and one patient presented after cholecystectomy from intraoperative bile duct injury. After access to the biliary system was obtained, a cholangiogram was obtained. After the desired duct was isolated, it was copiously irrigated with saline solution. A glue solution containing NBCA glue, Ethiodol, and tantalum powder was delivered into the duct through a polyethylene catheter that had been irrigated with dextrose solution. RESULTS: Four patients had problems arising from isolated segmental ductal systems that had no communication with the normal biliary ductal system and were treated successfully on the first attempt. In two patients, there was communication to the main biliary ductal system and a persistent bile leak occurred that required placement of a coil and a second final gluing procedure. The only complication observed was unintentional spillage of glue into the main biliary system in one patient, which was ultimately clinically insignificant. CONCLUSIONS: The use of NBCA glue in obliteration of bile ducts is a safe procedure with excellent results in patients with complications from isolated segmental ducts. Although a repeat procedure may be necessary if the duct communicates with the main biliary tree, the procedure can decrease the morbidity associated with chronic external biliary drainage.     

Bile duct: analysis of percutaneous transluminal forceps biopsy in 130 patients suspected of having malignant biliary obstruction

PURPOSE: To evaluate percutaneous transluminal forceps biopsy in patients suspected of having a malignant biliary obstruction. MATERIALS AND METHODS: One hundred thirty consecutive patients (82 men and 48 women; mean age, 59 years) with obstructive jaundice underwent transluminal forceps biopsy during or after percutaneous transhepatic biliary drainage. The lesions involved the common bile duct (n = 58), common hepatic duct (n = 39), hilum (n = 14), ampullary segment of the common bile duct (n = 11), right or left intrahepatic bile duct (n = 5), or the entire extrahepatic bile duct (n = 3). In each patient, three to five specimens (mean, 4.1 specimens) were taken from the lesion with 5.4-F biopsy forceps. The final diagnosis for each patient was confirmed with pathologic findings at surgery, additional histocytologic data, or clinical and radiologic follow-up. Statistical analysis was performed with the chi(2) test; a P value < or =.05 was considered to indicate a significant difference. RESULTS: Ninety-eight of 130 biopsies resulted in correct diagnoses of malignancy. Five biopsy diagnoses proved to be true-negative. There were 27 false-negative diagnoses and no false-positive diagnoses. The diagnostic performance of transluminal forceps biopsy in malignant biliary obstructions was as follows: sensitivity, 78.4%; specificity, 100%; and accuracy, 79.2%. Sensitivity of biopsy in the 82 patients with cholangiocarcinoma was higher than in the 43 patients with malignant tumors other than cholangiocarcinoma (86.6% vs 62.8%, P <.005). Sensitivity was significantly lower in the ampullary segment of the common bile duct than in other sites (P <.01). No major complications related to the biopsy procedures occurred. CONCLUSION: Percutaneous transluminal forceps biopsy is a safe procedure that is easy to perform through a transhepatic biliary drainage tract. It provides relatively high accuracy in the diagnosis of malignant biliary obstructions.     

Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts

Percutaneous transhepatic biliary drainage (PTBD) have been described as an effective technique to obtain biliary access. Between January 1996 and December 2006, a total of 419 consecutive patients with endoscopically inaccessible bile ducts underwent PTBD. The current retrospective study evaluated success and complication rates of this invasive technique. PTBD was successful in 410/419 patients (97%). The success rate was equal in patients with dilated and nondilated bile ducts (p = 0.820). In 39/419 patients (9%) procedure related complications could be observed. Major complications occurred in 17/419 patients (4%). Patients with nondilated intrahepatic bile ducts had significantly higher complication rates compared to patients with dilated intrahepatic bile ducts (14.5% vs. 6.9%, respectively [p = 0.022]). Procedure related deaths were observed in 3 patients (0.7%). In conclusion, percutaneous transhepatic biliary drainage is an effective procedure in patients with dilated and nondilated intrahepatic bile ducts. However, patients with nondilated intrahepatic bile ducts showed a higher risk for procedure related complications.     

Treatment of iatrogenic biliary obstruction by balloon dilatation of a biliary jejunal fistula

Biliary obstruction and multiple hepatic abscesses occurred in a patient after ligation of a segmental branch of the right hepatic duct. The patient was successfully managed by transhepatic biliary drainage and balloon dilatation of an internal fistula that developed between the ligated duct and a Roux limb of jejunum. Internal biliary fistulas may be dilated using interventioanl radiologic techniques to permit nonobstructed bile flow. Implications for the nonsurgical treatment' of biliary strictures are discussed.     

Percutaneous transhepatic cholangiography and biliary drainage in pediatric liver transplant patients

OBJECTIVE: In children with liver transplants, percutaneous transhepatic cholangiography has a critical role in evaluation and treatment of biliary complications. The purpose of this study was to evaluate the technical success and complication rates of percutaneous transhepatic cholangiography and biliary drain placement in children who underwent liver transplantation. MATERIALS AND METHODS: Between January 1, 1995 and July 1, 1999, 120 pediatric percutaneous transhepatic cholangiography procedures were performed in 76 patients (34 boys, 42 girls; age range, 5 months to 18 years; mean age, 5.3 years). Patients had received left lateral segment, whole-liver, or split-liver transplant grafts. Retrospective review of all pertinent radiology studies and electronic chart review were performed. RESULTS: A diagnostic cholangiogram was obtained in 96% (115/120) of all procedures and drainage catheter placement was successful in 89% (88/99) of attempts. In patients with nondilated intrahepatic bile ducts, a diagnostic cholangiogram was obtained in 92% (46/50) of procedures, and drainage catheter placement was successful in 76% (19/25) of attempts. Minor complications occurred in 10.8% (13/120) of procedures and included transient hemobilia with mild drop in hematocrit level (n = 2), mild pancreatitis (n = 1), fever with bacteremia (n = 5), and fever with negative blood cultures (n = 5). Major complications occurred in 1.7% (2/120) of procedures and included sepsis (n = 1) and hemoperitoneum requiring immediate surgery (n = 1). CONCLUSION: Percutaneous transhepatic cholangiography and biliary drainage can be performed with high technical success and low complication rates in pediatric liver transplant patients, even in those with nondilated intrahepatic ducts.     

Mangafodipir trisodium-enhanced magnetic resonance cholangiography for detection of bile leaks

PURPOSE: To assess the value of contrast-enhanced magnetic resonance cholangiography with Teslascan perfusion for the detection and localization of trauma-induced and postoperative bile leaks. MATERIALS AND METHODS: Between October 2002 and December 2004, 7 patients with suspected bile duct leaks after trauma (n = 2) or surgery (n = 5) requiring morphological evaluation were included. MRI examination included single shot fast spin- echo T2 weighted and gradient echo T1 weighted images prior to and 112 minutes in average after IV administration of mangafodipir trisodium. The results of contrast enhanced MR cholangiography were correlated to surgery (n = 3), clinical course (n = 3) and percutaneous drainage (n = 1). RESULTS: Mangafodipir trisodium-enhanced imaging showed extravasated Teslascan in collections in 6 patients (86%) whereas the combination of T2 weighted images and mangafodipir trisodium enhanced images revealed biliary collections in 7 patients (100%). The fistula between bile duct and collection was visualized in 4 patients (57%) before mangafodipir trisodium perfusion and in 3 patients (43%) after injection. In one patient the fistula was visible only after injection. Combination of both pre- and post injection MR correctly depicted the origin of bile leak in 5 cases (71%). CONCLUSION: Mangafodipir trisodium-enhanced magnetic resonance cholangiography is a non invasive technique that can successfully detect the presence of bile duct leaks. The combination of T2 weighted MR cholangiography and mangafodipir trisodium-enhanced T1 weighted MR cholangiography increases the sensitivity in detection and localization of the site of bile leak.