Successful Treatment of Isolated Draining Intrahepatic Biliary Ducts in a Pediatric Liver Transplant Recipient Using Alcohol Sclerotherapy

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.

Diagnosis and management of biliary complications in pediatric living donor liver transplant recipients

The incidence of biliary complications (BCs) after living donor liver transplantation (LDLT) can reach 40%. Published data on the pediatric population are limited, and treatment protocols vary. Our aim was to describe the clinical scenario for BCs and treatment approaches after LDLT. Between October 1995 and December 2012, 489 pediatric LDLT procedures were performed. BCs developed in 71 patients (14.5%). Biliary strictures (BSs) developed in 45 (9.2%) patients, and bile leaks (BLs) developed in 33 patients (6.7%). The BL diagnosis was clinical in all cases, and 69.7% of the patients underwent surgery. Nearly half of the BS cases had clinical features or suggestive ultrasound findings. Liver biopsy findings suggested BSs in 51.7%. Percutaneous transhepatic cholangiography was performed in 95.6% of the BS patients. The success rate was 77% [mean number of percutaneous biliary interventions (PBIs) = 3.9 ± 1.98, median drainage time = 8 months]. In conclusion, BL patients can be managed with conservative therapy, even though most of these patients will ultimately be treated with surgery. Diagnosing a BS requires a high degree of clinical suspicion because the available resources for its identification can fail in up to 50% of cases. A higher number of PBIs and the use of a drainage catheter for a longer time may be required to achieve better results with this technique.

A novel rat model simulating biliary atresia after a Kasai operation

PURPOSE

The mechanisms of liver fibrosis in biliary atresia (BA) after a Kasai operation deserve studying to improve the clinical outcomes. This study aimed to create a rat model simulating BA after a Kasai operation.

METHODS

We inserted a polyethylene tube (PE10) into the common hepatic duct (CHD) and ligated the common bile duct (CBD) in 30 newborn rats and injected 95% ethanol into IHD at postoperative week-one (POW-1). The PE10 was removed at POW-3. The rats were sacrificed at POW-5. The CBD cystojejunostomy was performed on another 10 rats at POW-5.

RESULTS

The IHD obliteration and CBD dilatation were noted at POW-3 cholangiography before removal of the PE tube. The gross findings at sacrifice in the rats without cystojejunostomy included biliary fibrosis, CBD cyst, and IHD obliteration. The microscopic findings of the liver were like BA. Seven of the 10 rats with CBD cystojejunostomy were jaundice-free at POW-8. The fibrosis grade at POW-8 of the rats with CBD cystojejunostomy was significantly lower in the jaundice-free rats (Ishak fibrosis score, 3.4 ± 0.9 and 1.5 ± 0.3 in the jaundiced rats and jaundice-free rats, respectively, p < .05).

CONCLUSION

Based on our study, CBD cystojejunostomy five weeks after CBD ligation with ethanol injection into the IHD in newborn rats can provide a model for investigating mechanisms and treatments of liver fibrosis in BA after a Kasai operation.

Management of excluded bile ducts in paediatric orthotopic liver transplant recipients of technical variant allografts

BACKGROUND

A strategy to increase the number of size- and weight-appropriate organs and decrease the paediatric waiting list mortality is wider application of sectional orthotopic liver transplantation (OLT). These technical variants consist of living donor, deceased donor reduced and split allografts. However, these grafts have an increased risk of biliary complications. An unusual and complex biliary complication which can lead to graft loss is inadvertent exclusion of a major segmental bile duct. We present four cases and describe an algorithm to correct these complications.

METHODS

A retrospective review of the paediatric orthotopic liver transplantation database (2000-2010) at Washington University in St. Louis/St. Louis Children's Hospital was conducted.

RESULTS

Sixty-eight patients (55%) received technical variant allografts. Four complications of excluded segmental bile ducts were identified. Percutaneous cholangiography provided diagnostic confirmation and stabilization with external biliary drainage. All patients required interval surgical revision of their hepaticojejunostomy for definitive drainage. Indwelling biliary stents aided intra-operative localization of the excluded ducts. All allografts were salvaged.

DISCUSSION

Aggressive diagnosis, percutaneous decompression and interval revision hepaticojejunostomy are the main tenets of management of an excluded bile duct. Careful revision hepaticojejunostomy over a percutaneous biliary stent can result in restoration of biliary continuity and allograft survival.

Percutaneous management of biliary leaks: biliary embosclerosis and ablation

Biliary leaks after hepatobiliary surgery are not uncommon. In certain situations minimal invasive percutaneous techniques may result in avoidance or reduction of the extent of surgery. Minimal invasive percutaneous techniques include (1) percutaneous bile collection (biloma) drainage, (2) percutaneous transhepatic biliary drainage, (3) biliary leak site embolization/sclerosis, and (4) leaking biliary segment ablation. There are two clinical applications for biliary ablation. The first is actual bile leak site ablation or embosclerosis to reduce an aperture or ablate a fistula (block a hole). The second is ablating an entire biliary segment to cease bile production and induce hepatic segmental atrophy (cease bile production). This article discusses the techniques used for biliary leak site embosclerosis/ablation (including biliary-cutaneous tract ablation) and biliary segmental ablation.