Ethanol ablation for segmental bile duct leakage after hepatobiliary resection

Endoscopic biliary ethanol ablation using a novel multi-hole balloon catheter: In vivo feasibility study in a swine model

BACKGROUND

Minimally invasive local treatment could be a good option for the treatment of extrahepatic cholangiocarcinoma (eCCA). This study aimed to evaluate the feasibility of a novel local treatment method, endoscopic biliary ethanol ablation (EA), in vivo using a swine model.

METHODS

This study utilized a prototype of the newly developed multi-hole balloon catheter. The swine bile duct was ablated using this balloon via the same approach as the conventional endoscopic retrograde cholangiography procedure. The study outcomes included technical success, clinical success, and adverse events associated with endoscopic biliary EA.

RESULTS

Fourteen miniature pigs underwent endoscopic biliary EA. Technical success was achieved for all endoscopic EA procedures without any hindrance. All pigs were reared and followed up for a median 35-day period after the procedure. No change was observed in the bile duct wall in one case, in which sufficient contact was not achieved between the balloon and bile duct wall. Except for this case, stricture formation occurred at the site of ablation, where the epithelium was sloughed and necrosis with denaturation replaced the granulation tissue and fibrotic changes. The median length and depth of the ablation area were 17.05 and 2.21 mm, respectively. No adverse events were observed, except for the formation of bile duct strictures and sequelae associated with strictures.

CONCLUSIONS

This preliminary study was the first to report endoscopic biliary EA using a novel multi-hole balloon catheter, which demonstrated technical feasibility and potential for the treatment for eCCA.

The role of interventional radiology in the management of refractory bile leaks

Refractory bile leaks represent a damaging sequela of hepatobiliary surgery and direct trauma. Management of bile leaks represents a challenging clinical problem. Despite advances in endoscopic techniques, interventional radiology continues to play a vital role in the diagnosis and management of refractory bile leaks. This article reviews strategies for optimizing the diagnosis and management of bile leaks and provides an overview of management strategies, including the management of complicated biliary leaks.

Percutaneous transhepatic techniques for management of biliary anastomotic strictures in living donor liver transplant recipients

AIM

To retrospectively analyze the percutaneous transhepatic techniques and their outcome in the management of biliary strictures in living donor liver transplant (LDLT) recipients.

MATERIALS AND METHODS

We retrieved the hospital records of 400 LDLT recipients between 2007 and 2015 and identified 45 patients with biliary strictures. Among them, 17 patients (37.8%) (Male: female = 13:4; mean age, 36.1 ± 17.5 years) treated by various percutaneous transhepatic biliary techniques alone or in combination with endoscopic retrograde cholangiopancreatography (ERCP) were included in the study. The technical and clinical success of the percutaneous management was analyzed.

RESULTS

Anastomotic strictures associated with leak were found in 12/17 patients (70.6%). Ten out of 12 (83.3%) patients associated with leak had more than one duct-duct anastomoses (range, 2-3). The average duration of onset of stricture in patients with biliary leak was 3.97 ± 2.68 months and in patients with only strictures it was 14.03 ± 13.9 months. In 6 patients, endoscopic-guided plastic stents were placed using rendezvous technique, plastic stent was placed from a percutaneous approach in 1 patient, metallic stents were used in 2 patients, cholangioplasty was performed in 1 patient, N-butyl- 2-cyanoacrylate embolization was done in 1 child with biliary-pleural fistula, internal-external drain was placed in 1 patient, and only external drain was placed in 5 patients. Technical success was achieved in 12/17 (70.6%) and clinical success was achieved in 13/17 (76.5%) of the patients. Posttreatment mean time of follow-up was 19.4 ± 13.7 months. Five patients (29.4%) died (two acute rejections, one metabolic acidosis, and two sepsis).

CONCLUSIONS

Percutaneous biliary techniques are effective treatment options with good outcome in LDLT patients with biliary complications.

Treatment strategy for isolated bile leakage after hepatectomy: Literature review

Isolated bile leakage (IBL) after hepatectomy is intractable, and various treatment methods for it have been reported. This review aimed to clarify the treatment strategy for IBL by summarizing studies on IBL after hepatectomy without extrahepatic bile duct resection. Thirty-three cases of IBL were reported. The incidence of IBL is very low, accounting for 0.1%-1% of all hepatectomy cases. The risk factors for IBL are unclear; however, several reports mention that biliary anomaly is associated with a high risk of IBL, with preoperative and intraoperative confirmation of biliary tree anatomy being the most important preventive strategy. Treatment methods for IBL include liver resection, bilioenteric anastomosis, endoscopic treatment, bile duct ablation, percutaneous transhepatic portal vein embolization (PTPE), transcatheter arterial embolization, and use of fibrin glue. The therapeutic methods should be chosen depending on remnant liver function, amount of bile leakage, and the liver volume causing the bile leakage. When there is bile leakage from less than one segment, non-surgical treatment is recommended, whereas when there is bile leakage from one or more segments, surgical treatment can be recommended. Nevertheless, recently, non-surgical treatment such as PTPE, PTPE with bile duct ablation, and endoscopic methods have been considered as effective treatment approaches.

Anterograde bile duct drainage for intractable bile leakage after hepatectomy in a patient with previous pancreatoduodenectomy: A case report

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Endoscopic retrograde drainage is effective for managing bile leakage.

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Bile drainage after pancreatoduodenectomy with choledochojejunostomy is difficult.

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Post-hepatectomy bile leakage in a patient with prior pancreatoduodenectomy.

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Selective anterograde bile duct drainage was successful in treating the condition.

Introduction

Endoscopic retrograde drainage is effective for managing bile leakage, which is relatively common after hepatectomy without bile duct reconstruction. However, the procedure is difficult to perform after pancreatoduodenectomy with choledochojejunostomy. We present a case of anterograde bile duct drainage for intractable bile leakage after hepatectomy in a patient with previous pancreatoduodenectomy.

Presentation of case

An 80-year-old woman with a history of pancreatoduodenectomy for distal biliary cancer and adjuvant chemotherapy presented with bile leakage. Six years after the pancreatoduodenectomy, she underwent partial hepatectomy for suspected metastasis or intrahepatic cholangiocarcinoma. On the 9th postoperative day, bile leaked from her drainage tube forming an abscess cavity; this continued until the 28th postoperative day. We attempted selective anterograde drainage from the cut surface of the liver under fluoroscopic guidance using a guidewire and Cobra-type catheter. We selectively cannulated the entrance hole of the bile duct. Twenty days after the drainage, the abscess cavity disappeared. After 41 days, the tube was removed, and the patient was discharged. We suggest this procedure as a possible treatment option for difficult bile leakage cases.

Discussion

A case of intractable bile leakage after hepatectomy in a patient with a previous history of pancreatoduodenectomy is difficult to manage, and usually needs surgical intervention. The effect of selective cannulation of the entrance hole of the bile duct has not been studied.

Conclusion

Selective anterograde bile duct drainage for intractable bile leakage after hepatectomy in a patient with a previous history of pancreatoduodenectomy successfully resolved bile duct leakage in our patient.

Successful treatment of isolated bile leakage after hepatectomy combination therapy with percutaneous transhepatic portal embolization and bile duct ablation with ethanol: a case report

Background

Bile leakage after hepatectomy still causes relatively serious problems, and some types of bile leakage are intractable.

Case presentation

We report a case of postoperative isolated bile duct leakage managed successfully by combination therapy of percutaneous transhepatic portal vein embolization (PTPE) and bile duct ablation with ethanol. A 61-year-old man diagnosed with hepatocellular carcinoma underwent partial hepatectomy. On postoperative day 1, bile leakage was detected at the drainage tube. Simple drainage treatment did not improve the situation. He was diagnosed with isolated bile leakage based on fistulogram from the drainage tube that showed the bile duct at segments V and VIII but not the common bile duct. A volume of drainage fluid of 200 mL/day was observed. Combination therapy with PTPE and bile duct ablation with ethanol was planned. After the percutaneous transhepatic cholangiography, the drainage tube was inserted into the bile duct, and PTPE was performed to segments V and VIII. The amount of drainage fluid decreased, and bile duct ablation with ethanol was performed to the isolated bile duct. No complication was found following combination therapy.

Conclusion

In this case, we successfully treated a patient with isolated bile leakage by combination therapy with PTPE and bile duct ablation.

Ethanol ablation for refractory bile leakage after complex hepatectomy

BACKGROUND

Only a few reports exist on the use of ethanol ablation for posthepatectomy bile leakage. The aim of this study was to assess the value of ethanol ablation in refractory bile leakage.

METHODS

Medical records of consecutive patients who underwent a first hepatobiliary resection with bilioenteric anastomosis between 2007 and 2016 were reviewed retrospectively, with special attention to bile leakage and ethanol ablation therapy. Bile leakage was graded as A/B1/B2 according to the International Study Group of Liver Surgery definition. Absolute ethanol was injected into the target bile duct during fistulography.

RESULTS

Of the 609 study patients, 237 (38·9 per cent) had bile leakage, including grade A in 33, grade B1 in 18 and grade B2 in 186. Left trisectionectomy was more often associated with grade B2 bile leakage than other types of hepatectomy (P < 0·001). Of 186 patients with grade B2 bile leakage, 31 underwent ethanol ablation therapy. Ethanol ablation was started a median of 34 (range 15-122) days after hepatectomy. The median number of treatments was 3 (1-7), and the total amount of ethanol used was 15 (3-71) ml. Complications related to ethanol ablation included transient fever (27 patients) and mild pain (13). Following ethanol ablation, bile leakage resolved in all patients and drains were removed. The median interval between the first ablation and drain removal was 28 (1-154) days.

CONCLUSION

Ethanol ablation is safe and effective, and may be a treatment option for refractory bile leakage.

Postoperative Biliary Leak Treated with Chemical Bile Duct Ablation Using Absolute Ethanol: A Report of Two Cases

Case series

Patient: Female, 72 • Male, 78

Final Diagnosis: Postoperative biliary leakage

Symptoms: Refractory and intractable symptoms

Medication: —

Clinical Procedure: Chemical ablation

Specialty: Surgery

Acetic acid sclerotherapy for treatment of biliary leak from an isolated right posterior sectoral duct after cholecystectomy

Bile duct injury is one of the most serious complications of both laparoscopic and open cholecystectomy. Isolated bile duct injury can occur from the misidentification of aberrant right hepatic ducts, and it is troublesome because the early diagnosis is easy to miss and the definite treatment is controversial. We report a case of an isolated right posterior sectoral duct injury following cholecystectomy managed successfully with acetic acid sclerotherapy combined with coil embolization for a fistula tract.

Risk Factors and Managements of Bile Leakage After Hepatectomy

BACKGROUND

The purpose of this study was to retrospectively determine the risk factors and evaluate the management of bile leakage.

METHODS

Three hundred and thirty-four patients who underwent hepatectomy for Child classification grade A liver disease, without biliary reconstruction and laparoscopic procedures, between 2003 and 2013 were included. Risk factors were identified using multivariate analysis.

RESULTS

Bile leakage was observed in 30 (9.0%) patients. Multivariate analysis demonstrated that type of hepatectomy (segmentectomy 1, medial sectionectomy, anterior sectionectomy, or central bisectionectomy) and operating time was independent risk factors for bile leakage. Among 30 patients with confirmed bile leakage, central type leakage that was in communication with the biliary tree occurred in 23 (76.7%) patients and peripheral type, which was not in communication with the biliary tree, in 7 (23.3%) patients. Ten patients were treated with only drainage. Endoscopic or percutaneous transhepatic procedures were performed in 15 cases with central type leakage. Ablation treatment using ethanol or minocycline was mainly performed for peripheral type leakage. Four cases with central type leakage had strictures of the right hepatic duct. Two of them were treated with ablation treatment, portal vein embolization, or fistulojejunostomy. Median duration from diagnosis to end of therapy was 77 days (11-323) in central type and 44 days (6-123) in peripheral type leakage, respectively.

CONCLUSIONS

Complex hepatectomy and operating time are independent risk factors for postoperative bile leakage. Biliary exploration should be performed as soon as possible after diagnosis, because most bile leakage is the central type. Central type of bile leakage is sometimes refractory to therapy, needing various treatments and requiring a long time for recovery.

Ethylene-vinyl alcohol copolymer endobiliary obliteration of hepatic segments in a patient with isolated bile leaks

A 54-year-old woman with a symptomatic giant hepatic hemangioma underwent an extended left hepatic trisegmentectomy complicated by 250-350 mL/d postoperative bilious drainage. After 5 months of therapy, drainage was unabated, and the patient was no longer a surgical candidate. Sinography revealed three distinct isolated bile duct leaks involving segments 6, 7, and 8. Endobiliary segmentectomy was achieved by obliterating the isolated systems with ethylene-vinyl alcohol copolymer (Onyx; ev3, Plymouth, Minnesota) during three fluoroscopic procedures. Bilious leaks were successfully eliminated, and compensatory hypertrophy of noninvolved liver occurred. At 2 years from the last embolization procedure, the patient remained asymptomatic with no bilious leak.

The determination of bile leakage in complex hepatectomy based on the guidelines of the International Study Group of Liver Surgery

BACKGROUND

The International Study Group of Liver Surgery (ISGLS) has defined bile leakage as a drain fluid-to-serum total bilirubin concentration (TBC) ratio (the bilirubin ratio) ≥ 3.0. The aim of the present study was to determine the clinical significance of this definition, and to outline characteristics of bile leakage in complex hepatectomy.

METHODS

The TBCs of the serum and drain fluid were measured on postoperative days (POD) 1, 3, and 7 in 241 patients who had undergone hepatobiliary resection. The validation of the bilirubin ratio and predictors of bile leakage were retrospectively assessed.

RESULTS

Grade A, B, or C bile leakage was found in 23 (9.5 %), 66 (27.4 %), and 0 patients, respectively. The median duration of drainage was 27 days in grade B bile leakage. The sensitivity and specificity of the bilirubin ratio for detecting grade B bile leakage were 59 and 87 %, respectively. The area under the receiver operating characteristics curve of the drain fluid TBC on POD 3 had the highest predictive value: 68 % sensitivity and 76 % specificity for a drain fluid TBC of 3.7 mg/dL. The multivariate analysis demonstrated that operative time, left trisectionectomy, bilirubin ratio, and TBC of the drain fluid on POD 3 were independent predictors of grade B bile leakage.

CONCLUSIONS

In complex hepatectomy, bile leakage develops most frequently after left trisectionectomy and often results in a refractory clinical course. The ISGLS biochemical definition is valid, and a combination of bilirubin ratio and drain fluid TBC may enhance risk prediction for grade B bile leakage.

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.

Assessing resectability in cholangiocarcinoma

Assessment of surgical resectability in cholangiocarcinoma is more complicated than other gastrointestinal malignancies and remains unestablished. According to the primary origin and tumor extent, the applied surgical procedure varies from extrahepatic bile duct resection to right or left trisectionectomy concomitant with pancreatoduodenectomy. Portal vein resection and reconstruction during hepatectomy has been feasible. Thanks to the availability of new microscopic surgical techniques, hepatic arterial resection and reconstruction have also come to be applied for locally advanced cholangiocarcinoma cases. These vascular surgical techniques can expand surgical indications for advanced cholangiocarcinoma. On the other hand, determination of the tumor extent or staging still remains difficult and imprecise. The endoscopic approach has come to play significant roles both for preoperative biliary drainage and tumor staging. Estimation of the functional reserve of future remnant liver in cholestatic patients still remains unresolved. Hepatobiliary surgeons should carefully estimate the safety of the surgical procedure in each individual patient requiring extensive hepatobiliary resection. Early establishment of the measurement methods of the functional capacity of future remnant liver is an important and urgent issue for assessing safer surgical resectablity of cholangiocarcinoma.

Percutaneous transhepatic embolization of biliary leakage with N-butyl cyanoacrylate

Biliary leakage is a known complication after biliary surgery. In this report, we describe an uncommon treatment of a common biliary complication, wherein we used percutaneous transhepatic injection of N-butyl cyanoacrylate (NBCA) to treat a biliary leak in an 83-year-old patient.

Portal vein embolization for an intractable bile leakage after hepatectomy

Bile leakages due to interruption of the intrahepatic bile duct after hepatectomy are often intractable. We herein report a case where portal vein embolization (PVE) decreased the bile production from the embolized part of the liver, which lead to healing of this type of bile leakage. A 77-year old man who had undergone an anterior segmentectomy of the liver for hepatocellular carcinoma 3 years prior was admitted to our hospital for an abscess in the right subphrenic space, and underwent percutaneous drainage. Fluoroscopy using a contrast medium from the drainage tube revealed that the root of the posterior branch of the bile duct was completely interrupted. The hilar side of the interrupted bile duct was closed, and all the bile from the posterior segment continued to be discharged at a rate of 100-150 ml/day for 2 months. The posterior branch of the portal vein was then embolized with fibrin glue by percutaneous transhepatic approach. After the PVE, the volume of discharge gradually decreased, and the drainage tube was removed 2 weeks after the PVE. Three months later, the patient was afebrile and doing well. PVE might be a useful method for treating interrupted type postoperative bile leakages.

Segmental bile duct leakage after hepatic resection managed with percutaneous ablation by N-butyl cyanoacrylate

A biloma is a rare abnormal accumulation of intrahepatic or extrahepatic bile caused by a traumatic or spontaneous rupture of the biliary tree. The reported incidence of postoperative biloma ranges from 4.8% to 7.6%. Biliary drainage is usually important and necessary for the treatment of biloma, but sometimes bile leakage fails to improve despite prolonged conservative drainage. We report a case of postoperative refractory biliary leakage managed with percutaneous ablation by N-butyl cyanoacrylate.

Bile duct leaks from the intrahepatic biliary tree: a review of its etiology, incidence, and management

Bile leaks from the intrahepatic biliary tree are an important cause of morbidity following hepatic surgery and trauma. Despite reduction in mortality for hepatic surgery in the last 2 decades, bile leaks rates have not changed significantly. In addition to posted operative bile leaks, leaks may occur following drainage of liver abscess and tumor ablation. Most bile leaks from the intrahepatic biliary tree are transient and managed conservatively by drainage alone or endoscopic biliary decompression. Selected cases may require reoperation and enteric drainage or liver resection for management.

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.

Management of excluded segmental bile duct leakage following liver resection

BACKGROUND

Postoperative bile leak secondary to a fistula is a known complication of hepatic surgery. Four different biliary fistula sub-types have been described: type A refers to minor leakage from the bile duct stump; type B to major leakage caused by insufficient closure of the bile duct stump; type C to major leakage caused by injury to the bile duct, and type D (the rarest) to the division and exclusion of a bile duct. This complication results from functional liver parenchyma in which bile drainage is excluded from the main duct.

METHODS

A retrospective review of the database for 163 patients diagnosed with post-hepatic surgery bile leak from April 1992 to June 2007 was performed.

RESULTS

Three patients were found to have type D biliary fistula, with durations of 3-21 months. The bile leak developed after a right hepatectomy in two patients and a right hepatectomy extending to segment IV in one patient. All three patients were rescheduled for surgical exploration, following failure of medical treatment. The procedure consisted of repeat resection of the independent liver parenchyma containing the fistula. One patient developed a postoperative leak from a hepaticojejunal anastomosis (treated conservatively) and the other two patients had an uneventful recovery. No recurrence of bile leak was encountered during their follow-up.

CONCLUSIONS

Our experience indicates that conservative treatment is deceptive and not efficacious. For this condition, surgical intervention is the treatment of choice because it is very effective and is associated with a low morbidity.

Biliary complications after orthotopic liver transplantation

Liver transplantation has made many advances since its inception in the early 1970s. Despite volumes of basic science and clinical research related to liver transplantation, biliary complications continue to present the interventional radiologist with challenging cases in all transplant centers. Biliary complications can range from minor complications such as contained bile leaks to severe complications such as biliary necrosis resulting from hepatic artery thrombosis. Minor complications may require minimal or no intervention, whereas the more severe complications can require urgent surgery. To treat biliary complications such as anastomotic strictures, nonanastomotic strictures, biliary leaks, sludge or biliary necrosis, an accurate diagnosis must first be obtained. One must also be aware of how these complications can impair both allograft and transplant patient survival. With this information one can then plan a treatment knowing the potential success rates of specific treatments. Using proper technique with this information at hand can greatly increase the success rate in treating the spectrum of biliary complications. Interventional radiology serves a critical role in diagnosis and treatment of these liver transplant biliary complications and is important to the success of all transplant programs.

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.

Ethanol injection for ablation of an intractable digestive tract fistula: report of a case

We successfully occluded an intractable digestive tract fistula by injecting it with absolute ethanol after all other treatments failed. A 48-year-old man suffered from a complex and relapsing digestive tract fistula after curative surgery for advanced colon cancer invading the pancreas and duodenum. After conservative management by fasting, drainage, and irrigation failed, fibrin glue infusion achieved only transient occlusion. We performed surgical repair and he was discharged from hospital, at which time fistulography showed no fistula. However, 1 month later fistulography showed that the fistula had recurred and involved the transverse colon, stomach, and intrahepatic bile duct via the jejunum. Finally, we gave five injections of absolute ethanol into the fistula, which resulted in complete occlusion within 6 months. Considering its clinical efficacy, safety, and cost efficiency, we think that ethanol sclerotherapy is a feasible treatment for intractable digestive tract fistula when conservative therapy fails.

Postoperative bile leakage managed successfully by intrahepatic biliary ablation with ethanol

We report a case of postoperative refractory bile leakage managed successfully by intrahepatic biliary ablation with ethanol. A 75-year-old man diagnosed with hepatocellular carcinoma underwent extended posterior segmentectomy including the caudate lobe and a part of the anterior segment. The hepatic tumor attached to the anterior branch of the bile duct was detached carefully and resected. Fluid drained from the liver surface postoperatively contained high concentrations of total bilirubin, at a constant volume of 150 mL per day. On d 32 after surgery, a fistulogram of the drainage tube demonstrated an enhancement of the anterior bile duct. Endoscopic retrograde cholangiography demonstrated complete obstruction of the proximal anterior bile duct and no enhancement of the peripheral anterior bile duct. On d 46 after surgery, a retrograde transhepatic biliary drainage (RTBD) tube was inserted into the anterior bile duct under open surgery. However, a contrast study of RTBD taken 7 mo post-surgery revealed that the fistula remained patent despite prolonged conservative management, so we decided to perform ethanol ablation of the isolated bile duct. Four mL pure ethanol was injected into the isolated anterior bile duct for ten minutes, the procedure being repeated five times a week. Following 23 attempts, the volume of bile juice reached less than 10 mL per day. The RTBD was clamped and removed two days later. After RTBD removal, the patient had no complaints or symptoms. Follow-up magnetic resonance imaging demonstrated atrophy of the ethanol-injected anterior segment without liver abscess formation.

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.

Acetic acid sclerotherapy for treatment of a biliary leak from an isolated bile duct after hepatic surgery

Bile duct leakage from the main biliary tree is not uncommon after hepatic surgery. In this case, successful percutaneous treatment was performed for bile leakage from an isolated bile duct after left hemihepatectomy in a 48-year-old woman who underwent surgery for biliary cystadenocarcinoma and developed a biloma at the left subphrenic space. Diagnostic procedures revealed that the right posterior segmental bile duct drained aberrantly into the left bile duct, which remained undrained after resection and led to biloma formation. Ablation of the isolated bile duct was performed with acetic acid, resulting in avoidance of repeated operation and other complications.

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.

A ten-year study on non-surgical treatment of postoperative bile leakage

AIM: To summarize systematically our ten-year experience in non-surgical treatment of postoperative bile leakage, and explore its methods and indications.

METHODS: The clinical data of 57 patients with postoperative bile leakage treated non-surgically from January 1991 to December 2000 were reviewed retrospectively.

RESULTS: The site of the leakage was mainly the disrupted or damaged fistulous tracts of T tube in 25 patients (43.9%), the fossae of gallbladder in 14 cases (24.6%), the cut surface of liver in 7 cases (12.3%), and it was undetectable in the other 2 cases. Besides bile leakage, the wrong ligation of bile ducts was found in 3 patients, residual stones of the distal bile duct in 5 patients, benign papillary strictures in 3, and biloma resulting from bile collections in 2. The diagnoses were made according to the history of surgery, clinical situation, abdominal paracentesis, ultrasonography, ERCP, PTC, MRI/MRCP, gastroscopy and percutaneous fistulography. All 57 patients were treated non-surgically at the beginning of bile leakage. The non-surgical methods included keeping original drainage unobstructed, percutaneous abdominal paracentesis or drainage, percutaneous transhepatic cholangial/biliary drainage (PTCD/PTBD), endoscopic management, traditional Chinese medicine and so on. Of the 57 patients, 2 patients died, 5 were converted to reoperation later, the other 50 were directly cured by non-surgical methods without any complication. The cure rate of the non-surgery was 82.5% (50/57).

CONCLUSION: Many nonoperative methods are available to treat postoperative bile leakage. Non-surgical treatment may serve as the first choice for the treatment of bile leakage for its advantages in higher cure rate, convenience and safety in practice. It is important to choose the specific non-surgical method according to the volume, site of bile leakage and patient's condition.

Incidence and management of bile leakage after hepatic resection for malignant hepatic tumors

BACKGROUND

Bile leakage is one of the frequent and disturbing complications of hepatic resection.

STUDY DESIGN

Clinical records of the 363 patients who underwent hepatic resections without biliary reconstruction for hepatic cancers between January 1994 and June 2001 were reviewed. Postoperative bile leakage was defined as continuous drainage with a bilirubin concentration of 20 mg/dL or 1,500 mg/d lasting 2 days. Leakage that continued longer than 2 weeks or that required surgical intervention was defined as uncontrollable. Differences in incidence and frequency of uncontrollable leakage for the different types of hepatic resection, tumors, and underlying liver disease were investigated. Outcomes after treatment for uncontrollable bile leakage were also reviewed.

RESULTS

Postoperative bile leakage occurred in 26 of 363 patients (7.2%). Although the incidence in patients with cholangiocellular carcinoma (3/9 [33%]) was higher (p = 0.03) than in patients with hepatocellular carcinoma, rates of occurrence were similar among the different types of hepatic resection and underlying liver disease. Eight of the 26 patients (31%) had uncontrollable leakage. Two patients required reoperation to control leakage; one of these developed hepatic failure and died 2 months after surgery. Four patients underwent endoscopic nasobiliary drainage 21 to 34 days after hepatectomy, and the leakage resolved within 3 to 21 days. Fibrin glue sealing was effective in two patients whose leaking bile ducts were not connected to the common bile duct.

CONCLUSIONS

Although meticulous surgical technique can minimize the risk of postoperative bile leakage, some instances of leakage are unavoidable. Nonsurgical treatments, such as nasobiliary drainage or fibrin glue sealing, are preferable to reoperation.