Management of obstructed biliary endoprostheses

In five patients with bile duct obstruction, a previously inserted endoprosthesis became occluded. After repeat percutaneous biliary drainage, the prostheses were mechanically unclogged, removed, or removed and replaced. No patient required surgery, and no prosthesis reoccluded. We discuss technique for deoccluding and, if necessary, removing and replacing obstructed stents.     

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.     

Unilocular Extrahepatic Biliary Cystadenoma Mimicking Choledochal Cyst: A Case Report

We report here on a case of extrahepatic biliary cystadenoma arising from the common hepatic duct. A 42-year-old woman was evaluated by us to find the cause of her jaundice. Ultrasonography and CT showed a cystic dilatation of the common hepatic duct and also marked dilatation of the intrahepatic duct. Direct cholangiography demonstrated a large filling defect between the left hepatic duct and the common hepatic duct; dilatation of the intrahepatic duct was also demonstrated. Following excision of the cystic mass, it was pathologically confirmed as a unilocular biliary mucinous cystadenoma arising from the common hepatic duct.     

Novel use of a T-tube access to perform an internal/external biliary drainage

We report a case of post-surgical temporary functional stenosis of the sphincter of Oddi and biliary leak in a patient with a previous Billroth II reconstruction who had undergone cholecystectomy, surgical choledocotomy and sphincterotomy for biliary calculi. The patient was treated by creation of an internal/external biliary drainage using the T-tube access with an unreported technique.     

Early removal of retained biliary stone without T-tube removal: Case report

Techniques for removal of retained common bile duct stones through mature tracts are safe and well established. When symptomatic, the stones may require removal prior to the 4–6-week period required for tract maturation. We report a case in which substituting a Teflon sheath for the standard polyethylene basket sheath allowed manipulation through the T-tube lumen and basketing of an impacted distal common bile duct stone, which had caused pancreatitis. This technique is simple and avoids the problem of loss of access to the biliary tree in the early postoperative period.     

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.     

Combined treatment of stone-obstructed hepatico-jejunostomy with interventional techniques and ESWL

In a 37-year-old woman with recurrent stenosis of a biliary digestive tract anastomosis and subsequent formation of bile stones, current methods of percutaneous management were useful in dilating the stenotic areas but could not remove a single bile stone within the left hepatic duct. It was successfully treated by using extracorporeal shock wave lithotripsy (ESWL) without major side effects.     

The role of radiology in the diagnosis and treatment of biliary complications after liver transplantation

Hepatic transplantation is now an accepted therapeutic option for selected patients with terminal liver disease. Biliary complications are, however relatively common after transplantation. We reviewed our experience with diagnostic and therapeutic biliary radiologic procedures in 151 hepatic recipients. Biliary complications were seen in 25% of patients. Interventional radiologic procedures were an integral part of the diagnostic and therapeutic management of these patients; reoperation was, nonetheless, occasionally required.     

Anatomic Variation in Intrahepatic Bile Ducts: an Analysis of Intraoperative Cholangiograms in 300 Consecutive Donors for Living Donor Liver Transplantation

Objective

To describe the anatomical variation occurring in intrahepatic bile ducts (IHDs) in terms of their branching patterns, and to determine the frequency of each variation.

Materials and Methods

The study group consisted of 300 consecutive donors for liver transplantation who underwent intraoperative cholangiography. Anatomical variation in IHDs was classified according to the branching pattern of the right anterior and right posterior segmental duct (RASD and RPSD, respectively), and the presence or absence of the first-order branch of the left hepatic duct (LHD), and of an accessory hepatic duct.

Results

The anatomy of the intrahepatic bile ducts was typical in 63% of cases (n=188), showed triple confluence in 10% (n=29), anomalous drainage of the RPSD into the LHD in 11% (n=34), anomalous drainage of the RPSD into the common hepatic duct (CHD) in 6% (n=19), anomalous drainage of the RPSD into the cystic duct in 2% (n=6), drainage of the right hepatic duct (RHD) into the cystic duct (n=1), the presence of an accessory duct leading to the CHD or RHD in 5% (n=16), individual drainage of the LHD into the RHD or CHD in 1% (n=4), and unclassified or complex variation in 1% (n=3).

Conclusion

The branching pattern of IHDs was atypical in 37% of cases. The two most common variations were drainage of the RPSD into the LHD (11%) and triple confluence of the RASD, RPSD and LHD (10%).     

Radiological Spectrum of Intraductal Papillary Tumors of the Bile Ducts

Papillary tumor of the bile duct is characterized by the presence of an intraductal tumor with a papillary surface comprising innumerable frondlike infoldings of proliferated columnar epithelial cells surrounding slender fibrovascular stalks. There may be multiple tumors along the bile ducts (papillomatosis or papillary carcinomatosis), which are dilated due to obstruction by a tumor per se, by sloughed tumor debris, or by excessive mucin. Radiologically, the biliary tree is diffusely dilated, either in a lobar or segmental fashion, or aneurysmally, depending on the location of the tumor, the debris, and the amount of mucin production. A tumor can be depicted by imaging as an intraductal mass with a thickened and irregular bile duct wall. Sloughed tumor debris and mucin plugs should be differentiated from bile duct stones. Cystically or aneurysmally, dilated bile ducts in mucin-hypersecreting variants (intraductal papillary mucinous tumors) should be differentiated from cystadenoma, cystadenocarcinoma and liver abscess.     

Multislice CT cholangiography without biliary contrast agent: technique and initial clinical results in the assessment of patients with biliary obstruction

Our objective was to describe our technique for multislice CT cholangiography without cholangiographic contrast agent, and to present our preliminary clinical results. Thirty-seven patients with suspected biliary obstruction were studied. A multislice CT unit was used with the following technical parameters: 2.5-mm collimation; 7.5-mm/s table speed; pitch 6; 0.8-s rotation time; 300 mA; 120 kVp; 18- to 24-s scan time; scan volume ranging from the hepatic dome to below the pancreatic head; 70-s delay after injection of 150 ml of iodinated contrast agent at 4 ml/s. No biliary contrast material was given; oral iodinated contrast agent was administered to opacify bowel loops. Axial, multiplanar reformatted, and minimum intensity projection images were evaluated. The CT findings were compared with the gold standard techniques: endoscopic retrograde cholangiography (ERCP) in 30 patients, percutaneous transhepatic cholangiography in 5, and intraoperative cholangiography in 2. In 5 patients with ampullary lesions biopsy was made during ERCP, 9 underwent surgery, and 11 US-guided fine-needle aspiration. Bile ducts appeared hypodense within the surrounding enhanced structures. Regarding the site of obstruction, agreement between multislice CT and conventional cholangiography was observed in all cases. One patient presented negative findings on both CT and ERCP. In 31 of 36 (86%) patients, multislice CT cholangiography without cholangiographic contrast agent correctly assessed the cause of bile duct obstruction. Multislice CT cholangiography without cholangiographic contrast agent seems to be a promising diagnostic tool in the assessment of patients with bile duct obstruction. Electronic Publication     

Biliary cystadenoma of the left intrahepatic duct (2007: 2b)

Biliary cystadenoma is a rare epithelial cystic neoplasm representing only 5% of intrahepatic cystic lesions of biliary origin. Commonly, the lesions are solitary cystic structures with multiple thin-walled septa predominantly arising from the right hepatic duct. Although the lesions are generally intrahepatic, extrahepatic tumors have been reported. Biliary cystadenomas range in diameter from 1.5 to 35 cm. The tumor usually affects middle-aged women. Clinical symptoms are related to the mass effect and comprise episodes of jaundice due to biliary obstruction and intermittent upper abdominal pain. Laboratory parameters are nonspecific. As the tumor is considered a premalignant lesion, complete surgical resection is the treatment of choice. We report a case of typical biliary cystadenoma of the left hepatic duct.     

Chronic bile peritonitis with progressive bile ascites: A complication of percutaneous biliary drainage

Percutaneous transhepatic biliary drainage procedures are associated with a small but definite incidence of complications. One of the most feared complications, leakage of bile, is commonly presumed to be a catastrophic clinical event. We present an unusual case in which a patient manifested only minimal abdominal symptoms associated with a massive biliary ascites. The bile leakage was first detected by diisopropyl iminodiacetic acid (DISIDA) scanning.     

Use of articulated catheters in the treatment of biliary strictures

We have used a single articulated catheter to obviate the need for multiple catheters in patients with complex biliary strictures or strictures associated with small or immature tracts. Two- and three-arm articulated drains (8–14 Fr) made from segments of biliary catheters were placed in 16 patients. Nine were placed transhepatically, 6 transperitoneally through existing T-tube tracts, and 1 through a cystic duct fistula. Six malignant and 10 benign strictures were stented with various catheter configurations through a single tract. Fifteen patients had two catheter components with one articulation and 1 patient had three catheter components with two articulations. The average duration of catheter drainage was 7.0 ± 4.2 months. Routine catheter exchanges were performed; two spontaneous occlusions occurred. In patients where internal stenting may be difficult or undesirable, articulated catheters allow satisfactory external and internal drainage of complex benign and malignant strictures through a single tract, avoiding the need for multiple transhepatic catheters.     

Spectrum of biliary abnormalities in hepatic hereditary hemorrhagic telangiectasia: demonstration by multidetector computed tomography

We present a case in which multidetector computed tomography demonstrated a specific pattern of biliary disease associated with hepatic hereditary hemorrhagic telangiectasia: multiple intrahepatic stenoses, focal cystic dilatations along the course of the intrahepatic ducts, and large biliary cysts in conjunction with a normal-appearing extrahepatic bile duct.     

经皮肝胆管穿刺金属内支架植入治疗恶性梗阻性黄疸

目的：探讨经皮肝胆管穿刺金属内支架植入治疗恶性梗阻性黄疸临床应用价值。方法：108例患者中的9r7例均采用X线透视下经皮肝穿刺胆道内支架植入术治疗恶性梗阻性黄疸。根据梗阻部位的不同解剖决定放置支架的方式。结果：108例患者中,90例植入单支支架于肝总管或（和）胆总管,7例植入2支以上支架于总管和分支胆管,11例行外引流。全部患者2周内血清胆红素从（436±314）mol／L降低到（53±31）mol／L。结论：经皮肝穿刺内支架植入是治疗恶性胆道梗阻性的有效方法。     

Placement of biliary endoprosthesis through T-tube tract—case report

We report a case of obstructive jaundice in which the tract of a surgically placed T-tube was used as a route for easy access to stent a neoplastic stenosis of the common bile duct.     

高位肝门部胆管癌的外科治疗

目的分析55例高位胆管癌手术治疗方法和生存时间。方法回顾分析空军总医院1995年1月至2005年4月收治的55例高位肝门部胆管癌病人的临床资料。结果共有37例（37／55）行胆管癌切除,21例切除后生存24个月以上,4例死于15个月内,其余生存4～18个月,未切除者行胆汁内或外引流术并进行放射治疗,未接受手术者行经皮内或外引流。结论高位胆管癌外科手术治疗是主要手段,内外引流手术可以延长病人的生存时间。     

DSA引导下经T管调管并二次置入胆道引流管治疗肝胆术后胆汁漏4例

目的探讨利用导丝调整异常T管的位置并二次置入胆道引流管治疗肝胆手术术后胆汁漏的有效性及安全性。 方法回顾性分析2018年1月至2020年1月于我院在DSA引导下经T管调管并二次置入胆道引流管治疗肝胆术后胆汁漏的4例患者资料。经T管引入导丝导管,导丝导管配合,调整异常的T管并进入肝内胆管内,经导丝引入8.5F COOK胆道外引流管置于肝内胆管,行胆道负压外引流。总结评价治疗效果。 结果术后4例患者负压引流管引流通畅,胆汁漏逐渐停止,腹腔内感染得到控制。术后1个月复查造影,见引流管位置正常,无造影剂外溢至腹腔,2个月拔除T管及胆道引流管后,患者无特殊不适。随访1年,患者病情未再反复。 结论DSA引导下经T管调管并二次置入胆道引流管是治疗肝胆手术术后胆汁漏的安全有效的方法,可避免再次外科手术,减轻患者痛苦。     

Gadobenate Dimeglumine as an Intrabiliary Contrast Agent: Comparison with Mangafodipir Trisodium with Respect to Non-dilated Biliary Tree Depiction

Objective

To compare the efficacy of Mangafodipir trisodium (Mn-DPDP)-enhanced MR cholangiogrphy (MRC) and Gadobenate dimeglumine (Gd-BOPTA)-enhanced MRC in visualizing a non-dilated biliary system.

Materials and Methods

Eighty-eight healthy liver donor candidates underwent contrast-enhanced T1-weighted MRC. Mn-DPDP and Gd-BOPTA was used in 36 and 52 patients, respectively. Two radiologists reviewed the MR images and rated the visualization of the common duct, the right and left hepatic ducts, and the second-order branches using a 4-point scale. The contrast-to-noise ratio (CNR) of the common duct to the liver in the two groups was also compared.

Results

Mn-DPDP MRC and Gd-BOPTA MRC both showed similar visualization grades in the common duct (p = .380, Mann-Whitney U test). In the case of the proximal bile ducts, the median visualization grade was significantly higher with Gd-BOPTA MRC than with Mn-DPDP MRC (right hepatic duct: p = 0.016, left hepatic duct: p = 0.014, right secondary order branches: p = 0.006, left secondary order branches, p = 0.003). The common duct-to-liver CNR of the Gd-BOPTA MRC group was significantly higher (38.90±24.50) than that of the Mn-DPDP MRC group (24.14±17.98) (p = .003, Student''s t test).

Conclusion

Gd-BOPTA, as a biliary contrast agent, is a potential substitute for Mn-DPDP.