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Ohm JY, Ko GY, Sung KB, Gwon DI, Ko HK. Safety and efficacy of transhepatic and transsplenic access for endovascular management of portal vein complications after liver transplantation. Liver Transpl 2017; 23:1133-1142. [PMID: 28152572 DOI: 10.1002/lt.24737] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/07/2016] [Accepted: 01/16/2017] [Indexed: 01/10/2023]
Abstract
The purpose of this article is to evaluate and compare the safety and efficacy of endovascular management of the portal vein (PV) via percutaneous transsplenic access versus percutaneous transhepatic access in liver transplantation (LT) recipients. A total of 18 patients who underwent endovascular management of PV via percutaneous transhepatic (n = 8) and transsplenic (n = 10) access were enrolled. Transsplenic access was chosen if the spleen was located in a normal position, the splenic vein (SpV) was preserved, and the target lesion did not involve confluence of the superior mesenteric and SpVs. Accessibility of the percutaneous transsplenic puncture was confirmed via ultrasound (US) in the angiography suite. All procedures were performed under local anesthesia. Percutaneous transhepatic or transsplenic access was performed using a 21-gauge Chiba needle under US and fluoroscopic guidance, followed by balloon angioplasty, stent placement, or variceal embolization. The access tract was embolized using coils and a mixture (1:2) of glue and ethiodized oil. Transhepatic or transsplenic access was successfully achieved in all patients. A total of 12 patients underwent stent placement; 3 had balloon angioplasty only; 2 had variceal embolization only; and 1 had variceal embolization followed by successful stent placement. Regarding major complications, 1 patient experienced a SpV tear with extravasation during transsplenic balloon angioplasty, which was successfully managed using temporary balloon inflation, followed by transfusion. Clinical success was achieved in 9 of 11 (82%) patients who exhibited clinical manifestations. The remaining 7 patients who underwent prophylactic endovascular management were healthy. In conclusion, endovascular management of PV via percutaneous transsplenic access is a relatively safe and effective alternative that does not damage the liver grafts of LT recipients. Liver Transplantation 23 1133-1142 2017 AASLD.
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Affiliation(s)
- Joon-Young Ohm
- Department of Radiology, Chungnam National University Hospital, Daejeon, South Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyu-Bo Sung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong-Il Gwon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Heung Kyu Ko
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Qin JJ, Xia YX, Lv L, Wang ZJ, Zhang F, Wang XH, Sun BC. Successful disintegration, dissolution and drainage of intracholedochal hematoma by percutaneous transhepatic intervention. World J Gastroenterol 2012; 18:7122-7126. [PMID: 23323019 PMCID: PMC3531705 DOI: 10.3748/wjg.v18.i47.7122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 09/28/2012] [Indexed: 02/06/2023] Open
Abstract
Hemobilia is a rare biliary complication of liver transplantation. The predominant cause of hemobilia is iatrogenic, and it is often associated with traumatic operations, such as percutaneous liver intervention, endoscopic retrograde cholangiopancreatography, cholecystectomy, biliary tract surgery, and liver transplantation. Percutaneous transhepatic cholangiography and liver biopsy are two major causes of hemobilia in liver transplant recipients. Hemobilia may also be caused by coagulation defects. It can form intracholedochal hematomas, causing obstructive jaundice. Herein we describe a patient with an intracholedochal hematoma resulting in significant obstructive jaundice after liver transplantation for fulminant hepatic failure. Previous studies have shown that percutaneous transhepatic manipulation is a major cause of hemobilia after liver transplantation, but in our case, percutaneous transhepatic intervention was used to relieve the biliary obstruction and dissolve the biliary clot, with a good outcome.
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Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of the literature. Eur J Gastroenterol Hepatol 2012; 24:905-9. [PMID: 22617365 DOI: 10.1097/meg.0b013e328354ae1b] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Hemobilia is an uncommon cause of gastrointestinal bleeding. The etiology is diverse, but most often, it is iatrogenic. The present study aims to reassess the clinical picture and the treatment of choice. METHODS We describe a case series from a single center of patients who presented with nontraumatic iatrogenic hemobilia. RESULTS Over a period of 8 years, hemobilia occurred in 12 patients: following liver biopsy in six patients and after endoscopic biliary interventions in four patients, with a respective prevalence of 0.1 and 0.04%. The clinical presentation was characterized by an upper gastrointestinal bleeding (n=11) and/or biochemical signs of sudden biliary obstruction (n=9). The onset of the symptoms occurred after a median of 6 days (range: 1-23). Ultrasound and computed tomography scan missed the diagnosis in, respectively, 4/5 and 2/5 of patients. On arteriography, pseudoaneurysm (6/12) was the most common finding. Transcatheter arterial embolization controlled the bleeding in all cases (12/12) without major complications. CONCLUSION The delay between the intervention and the clinical presentation and the fact that imaging studies may fail to diagnose hemobilia may mislead the physician. Transcatheter arterial embolization is the treatment of choice for hemobilia. It has proven to be effective and safe and it offers a long-term definitive cure.
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Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011; 66:500-9. [PMID: 21371695 DOI: 10.1016/j.crad.2010.11.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 11/02/2010] [Indexed: 12/16/2022]
Abstract
AIM To assess the published evidence on the endovascular treatment of non-variceal upper gastrointestinal haemorrhage. MATERIALS AND METHODS An Ovid Medline search of published literature was performed (1966-2009). Non-English literature, experimental studies, variceal haemorrhage and case series with fewer than five patients were excluded. The search yielded 1888 abstracts. Thirty-five articles were selected for final analysis. RESULTS The total number of pooled patients was 927. The technical and clinical success of embolization ranged from 52-100% and 44-100%, respectively. The pooled mean technical/clinical success rate in primary upper gastrointestinal tract haemorrhage (PUGITH) only, trans-papillary haemorrhage (TPH) only, and mixed studies were 84%/67%, 93%/89%, and 93%/64%, respectively. Clinical outcome was adversely affected by multi-organ failure, shock, corticosteroids, transfusion, and coagulopathy. The anatomical source of haemorrhage and procedural variables did not affect the outcome. A successful embolization improved survival by 13.3 times. Retrospective comparison with surgery demonstrated equivalent mortality and clinical success, despite embolization being applied to a more elderly population with a higher prevalence of co-morbidities. CONCLUSIONS Embolization is effective in this very difficult cohort of patients with outcomes similar to surgery.
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Affiliation(s)
- S Mirsadraee
- Department of Radiology, Leeds General Infirmary, Leeds, UK
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Kim DS, Lee SG, Sung GB, Ko GY, Park KM, Kim KH, Ahn CS, Moon DB, Ha TY, Song GW. Management of subcapsular hematoma of the graft after living donor liver transplantation. Liver Transpl 2006; 12:1124-8. [PMID: 16799940 DOI: 10.1002/lt.20791] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Subcapsular hematoma of the graft is a serious complication of liver transplantation (LT), and there has been no discussion in the literature about optimal management except in sporadic case reports. The aim of this work is to review our experience of subcapsular hematoma in living donor liver transplantation (LDLT) and to introduce our management strategy. Among the 818 cases of adult-to-adult LDLT between February 1997 and November 2005, there have been 4 cases of subcapsular hematoma. Two of these developed after percutaneous liver biopsy and the other 2 developed after percutaneous transhepatic biliary drainage (PTBD). Two developed immediately after the procedure, whereas the other 2 developed 8 and 12 days after the procedure, respectively, due to rupture of a pseudoaneurysm. Our management strategy was as follows; after performing dynamic computed tomography for initial diagnosis, these 3 steps were taken: 1) hepatic arteriography and selective embolization of bleeding focus; 2) pigtail catheter drainage (PCD) of subcapsular hematoma; and 3) hepatic vein stenting if there was a sign of outflow disturbance due to compression by a large hematoma. All 4 of our patients recovered from the insult of subcapsular hematoma. In conclusion, our results indicate that patients who develop subcapsular hematoma after LDLT can be treated nonsurgically.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Baron P, Ben-Youssef R, Ojogho O, Franco E, Concepcion W, Smith D. Hemobilia secondary to a posttransplant lymphoma after liver transplantation. Transplantation 2005; 79:1766-7. [PMID: 15973184 DOI: 10.1097/01.tp.0000159111.36500.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lin CL, Chang JJ, Lee TS, Lui KW, Yen CL. Gallbladder polyp as a manifestation of hemobilia caused by arterial-portal fistula after percutaneous liver biopsy: A case report. World J Gastroenterol 2005; 11:305-7. [PMID: 15633239 PMCID: PMC4205425 DOI: 10.3748/wjg.v11.i2.305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Outpatient percutaneous liver biopsy is a common practice in the differential diagnosis and treatment of chronic liver disease. The major complication and mortality rate were about 2-4% and 0.01-0.33% respectively. Arterio-portal fistula as a complication of percutaneous liver biopsy was infrequently seen and normally asymptomatic. Hemobilia, which accounted for about 3% of overall major percutaneous liver biopsy complications, resulted rarely from arterio-portal fistula We report a hemobilia case of 68 years old woman who was admitted for abdominal pain after liver biopsy. The initial ultrasonography revealed a gallbladder polypoid tumor and common bile duct (CBD) dilatation. Blood clot was extracted as endoscopic retrograde cholangiopancreatography (ERCP) showed hemobilia. The patient was shortly readmitted because of recurrence of symptoms. A celiac angiography showed an intrahepatic arterio-portal fistula. After superselective embolization of the feeding artery, the patient was discharged uneventfully. Most cases of hemobilia caused by percutaneous liver biopsy resolved spontaneously. Selective angiography embolization or surgical intervention is reserved for patients who failed to respond to conservative treatment.
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Affiliation(s)
- Chih-Lang Lin
- Division of Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital and University, Keelung, Taiwan, China
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Maguire D, Rela M, Heaton ND. Biliary complications after orthotopic liver transplantation. Transplant Rev (Orlando) 2002. [DOI: 10.1053/trte.2002.1296481] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Jeng KS, Sheen IS, Yang FS. Vascular complications in percutaneous transhepatic management of complicated hepatolithiasis with difficult intrahepatic biliary strictures: are they avoidable? Surg Laparosc Endosc Percutan Tech 2002; 12:82-7. [PMID: 11948292 DOI: 10.1097/00129689-200204000-00002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Little has been reported about hemobilia in the management of complicated residual or recurrent hepatolithiasis with intrahepatic biliary strictures by percutaneous stricture dilation and percutaneous transhepatic cholangioscopic lithotomy. To analyze retrospectively the incidence, possible factors, and management of hemobilia in such patients, a consecutive series of 177 patients was studied from 1983 to 2001: 90 patients in the early, 7.5-year period and 87 patients in the later period, in which some procedures were modified. Minor hemobilia occurred during percutaneous puncture in 6 patients: 4 (4.4%) in the early period and 2 (2.3%) in the later period. Massive hemobilia developed in 14 patients (15.5%) in only the early period, during stricture dilation, lithotripsy, or lithotomy. Immediate arteriography revealed arterial bleeding (7), extravasation (3), pseudoaneurysm (3), or an undetermined source (1). Transcatheter arterial intervention enabled successful hemostasis. Massive hemobilia is a potential serious complication of percutaneous stricture dilation and percutaneous transhepatic cholangioscopic lithotomy but is avoidable.
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Affiliation(s)
- Kou-Shyang Jeng
- Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan, Republic of China
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Abstract
BACKGROUND The aim was to evaluate a non-operative approach to the management of haemobilia. METHODS This was a retrospective analysis of patients presenting over 10 years with haemobilia. All patients had upper gastrointestinal endoscopy, abdominal ultrasonography and digital subtraction angiography. Superselective coil and/or Gelfoam embolization was done as close as possible to the bleeding site. Completion angiography was performed routinely to confirm adequate embolization. RESULTS There were 23 patients with liver trauma and six with inflammatory conditions. All patients required resuscitation with fluids and blood transfusion, and had the haemobilia controlled successfully by angiographic embolization. There was one death from fulminant hepatic sepsis. CONCLUSION This series attests to the efficacy of a non-operative approach to haemobilia using radiological diagnosis and intervention.
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Affiliation(s)
- J Moodley
- Department of General Surgery, University of Natal, Durban, South Africa.
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Abstract
BACKGROUND This review aims to establish whether increased use of invasive procedures and the trend toward conservative management of major trauma has resulted in an increased incidence of haemobilia. METHOD A Medline (http://igm.nlm.nih.gov/)-based search of the English language literature from January 1996 to December 1999 inclusive was performed using the keywords haemobilia, hemobilia, haematobilia and hematobilia. The presentation, aetiology, investigation, management and outcome of 222 cases were reviewed. RESULTS Two-thirds of cases were iatrogenic while accidental trauma accounted for 5 per cent. Haemobilia may be major, constituting life-threatening haemorrhage, or minor; it may present many weeks after the initial injury. Diagnosis is most commonly confirmed by angiography. Management is aimed at stopping bleeding and relieving biliary obstruction; 43 per cent of cases were managed conservatively and 36 per cent were managed by transarterial embolization (TAE). Surgery was indicated when laparotomy was performed for other reasons and for failed TAE. The mortality rate was 5 per cent. CONCLUSIONS Although the incidence of iatrogenic haemobilia has risen considerably, the bleeding is often minor and can be managed conservatively. When more urgent intervention is required, TAE is usually the treatment of choice. There is no evidence that the conservative management of accidental liver trauma increases the risk of haemobilia.
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Affiliation(s)
- M H Green
- Department of Surgery, Southampton General Hospital, Southampton, UK.
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