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Husnain A, Malik A, Caicedo J, Nadig S, Borja-Cacho D, Boike J, Levitsky J, Reiland A, Thornburg B, Keswani R, Ebrahim Patel MS, Aadam A, Salem R, Duarte A, Ganger D, Riaz A. Percutaneous Biliary Interventions via the Modified Hutson Loop in Patients with Biliary-Enteric Anastomoses: A Retrospective Study. Cardiovasc Intervent Radiol 2024:10.1007/s00270-024-03778-x. [PMID: 38858255 DOI: 10.1007/s00270-024-03778-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 05/12/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE This study aimed to present the institutional experience and algorithm for performing biliary interventions in liver transplant patients using the modified Hutson loop access (MHLA) and the impact of percutaneous endoscopy via the MHLA on these procedures. METHODS Over 13 years, 201 MHLA procedures were attempted on 52 patients (45 liver transplants; 24 living and 21 deceased donors) for diagnostic (e.g., cholangiography) and therapeutic (e.g., stent/drain insertion and cholangioplasty) purposes. The most common indications for MHLA were biliary strictures (60%) and bile leaks (23%). Percutaneous endoscopy was used to directly visualize the biliary-enteric anastomosis, diagnose pathology (e.g., ischemic cholangiopathy), and help in biliary hygiene (removing debris/casts/stones/stents) in 138/201 (69%) procedures. Technical success was defined as cannulating the biliary-enteric anastomosis and performing diagnostic/therapeutic procedure via the MHLA. RESULTS The technical success rate was 95% (190/201). The failure rate among procedures performed with and without endoscopy was 2% (3/138) versus 13% (8/63) (P = 0.0024), and the need for new transhepatic access (to aid the procedure) was 12% (16/138) versus 30% (19/63) (P = 0.001). Despite endoscopy, failure in 2% of the cases resulted from inflamed/friable anastomosis (1/3) and high-grade stricture (2/3) obstructing retrograde cannulation of biliary-enteric anastomosis. Major adverse events (bowel perforation and injury) occurred in 1% of the procedures, with no procedure-related mortality. CONCLUSIONS MHLA-based percutaneous biliary intervention is a safe and effective alternative to managing complications after liver transplant. Percutaneous endoscopy via the MHLA improves success rates and may reduce the need for new transhepatic access. Level of Evidence Level 4.
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Affiliation(s)
- Ali Husnain
- Division of Interventional Radiology, Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Asad Malik
- Division of Interventional Radiology, Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Juan Caicedo
- Department of Surgery, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Satish Nadig
- Department of Surgery, Northwestern Memorial Hospital, Chicago, IL, USA
| | | | - Justin Boike
- Department of Medicine, Section of Gastroenterology and Hepatology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Josh Levitsky
- Department of Medicine, Section of Gastroenterology and Hepatology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Allison Reiland
- Division of Interventional Radiology, Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Bartley Thornburg
- Division of Interventional Radiology, Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Rajesh Keswani
- Department of Medicine, Section of Gastroenterology and Hepatology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Muhammed Sufyaan Ebrahim Patel
- Division of Interventional Radiology, Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Aziz Aadam
- Department of Medicine, Section of Gastroenterology and Hepatology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Riad Salem
- Division of Interventional Radiology, Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Andres Duarte
- Department of Medicine, Section of Gastroenterology and Hepatology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Daniel Ganger
- Department of Medicine, Section of Gastroenterology and Hepatology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Ahsun Riaz
- Division of Interventional Radiology, Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA.
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Raafat M, Morsy MM, Mohamed SI, Hamad MA, Sayed MM. Therapeutic Role of Subcutaneous Access Loop Created Adjunct to Hepaticojejunostomy for Management of Bile Duct Injury. Am Surg 2023; 89:5711-5719. [PMID: 37142256 DOI: 10.1177/00031348231173945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Roux-en-Y hepaticojejunostomy (RYHJ) is usually required for major bile duct injury (BDI) as a definitive treatment. Hepaticojejunostomy anastomotic stricture (HJAS) is the most feared long-term complication following RYHJ. The ideal management of HJAS remains undefined. The provision of permanent endoscopic access to the bilio-enteric anastomotic site can make endoscopic management of HJAS feasible and attractive option. In this cohort study, we aimed to evaluate short- and long-term outcomes of subcutaneous access loop created adjunct to RYHJ (RYHJ-SA) for management of BDI and its usefulness for endoscopic management of anastomotic stricture if occurred. MATERIALS AND METHODS This is a prospective study including patients who were diagnosed with iatrogenic BDI and underwent hepaticojejunostomy with subcutaneous access loop between September 2017 and September 2019. RESULTS This study included a total number of 21 patients whom ages ranged between 18 and 68 years. During follow-up, three cases had HJAS. One patient had the access loop in subcutaneous position. Endoscopy was done but failed to dilate the stricture. The other 2 patients had the access loop in subfascial position. Endoscopy of them failed to enter the access loop due to failure of fluoroscopy to identify the access loop. The three cases underwent redo-hepaticojejunostomy. Parajejunal (parastomal) hernia occurs in 2 patients in whom the access loop was fixed subcutaneous position. CONCLUSION In conclusion, modified RYHJ with subcutaneous access loop (RYHJ-SA) is associated with reduced quality of life and patient satisfaction. Moreover, its role in endoscopic management of HJAS after biliary reconstruction for major BDI is limited.
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Affiliation(s)
- Mohamad Raafat
- Department of General Surgery, Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Morsy M Morsy
- Department of General Surgery, Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Salah I Mohamed
- Department of General Surgery, Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Mostafa A Hamad
- Department of General Surgery, Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Mostafa M Sayed
- Department of General Surgery, Faculty of Medicine, Assiut University, Asyut, Egypt
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Costamagna G. Long-standing enteroenteric anastomosis with lumen-apposing metal stents to access bilioenteric anastomotic strictures: yes we can! Endoscopy 2021; 53:298-299. [PMID: 33631830 DOI: 10.1055/a-1258-4306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica S. Cuore, Rome, Italy
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Ishizawa T, Kobayashi T, Makino N, Matsuda A, Kakizaki Y, Sugawara S, Ashino K, Takahashi R, Motoi F, Ueno Y. A case of a smooth transition to subsequent percutaneous transjejunal biliary intervention for hepatolithiasis after biliary reconstruction by adding jejunostomy during an emergency operation for perforation due to balloon-assisted endoscopy. Clin J Gastroenterol 2021; 14:678-683. [PMID: 33400187 DOI: 10.1007/s12328-020-01312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/29/2020] [Indexed: 11/09/2022]
Abstract
Treatments for hepatolithiasis include peroral endoscopy, percutaneous cholangioscopy, and surgery. Balloon-assisted endoscopic retrograde cholangiopancreatography (BAERCP) has been widely performed in recent years for patients with hepatolithiasis after biliary reconstruction. However, accidental bowel perforation caused by BAERCP may need emergency surgery. Here, we describe a 77-year-old Japanese woman diagnosed with acute cholangitis due to hepatolithiasis after biliary reconstruction (a biliary diversion operation for pancreaticobiliary maljunction). She underwent BAERCP for treatment of hepatolithiasis, however, a small-bowel perforation occurred. She underwent an emergency operation to suture the perforation and add a catheter jejunostomy. She had no postoperative complications after surgery and was discharged 11 days after surgery. One month later, she was readmitted and underwent percutaneous transjejunal cholangioscopy-guided lithotripsy with complete removal of the calculi. Although endoscopists should be careful to avoid small-bowel perforation during BAERCP, if perforation occurs, addition of a catheter jejunostomy during emergency surgery can be easily transitioned to subsequent treatment of the hepatolithiasis.
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Affiliation(s)
- Tetsuya Ishizawa
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-8595, Japan.
| | - Toshikazu Kobayashi
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-8595, Japan
| | - Naohiko Makino
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-8595, Japan
| | - Akiko Matsuda
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-8595, Japan
| | - Yasuharu Kakizaki
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-8595, Japan
| | - Shuichiro Sugawara
- Department of Surgery I, Faculty of Medicine, Yamagata University, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-8595, Japan
| | - Koki Ashino
- Department of Surgery I, Faculty of Medicine, Yamagata University, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-8595, Japan
| | - Ryosuke Takahashi
- Department of Surgery I, Faculty of Medicine, Yamagata University, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-8595, Japan
| | - Fuyuhiko Motoi
- Department of Surgery I, Faculty of Medicine, Yamagata University, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-8595, Japan
| | - Yoshiyuki Ueno
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-8595, Japan
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Riaz A, Entezari P, Ganger D, Gabr A, Thornburg B, Russell E, Ladner D, Katariya N, Caicedo JC, Boike J, Lewandowski RJ, Keswani R, Aadam AA, Abecassis M, Salem R. Percutaneous Access of the Modified Hutson Loop for Retrograde Cholangiography, Endoscopy, and Biliary Interventions. J Vasc Interv Radiol 2020; 31:2113-2120.e1. [PMID: 32948389 DOI: 10.1016/j.jvir.2020.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The purpose of this study was to present the institutional experience of performing endoscopy, cholangiography, and biliary interventions through the modified Hutson loop by interventional radiology. MATERIALS AND METHODS A total of 61 of 64 modified Hutson loop access procedures were successful. This single-center retrospective study included 61 successful procedures of biliary interventions using existing modified Hutson loops (surgically affixed subcutaneous jejunal limb adjacent to biliary anastomosis or anastomoses) for diagnostic or therapeutic purposes in 21 patients. Seventeen of 21 patients (81%) had undergone liver transplantation. Indications included biliary strictures (n = 18) and biliary leaks (n = 3). The clinical success and complications were evaluated. RESULTS There were 3 of 26 modified Hutson loop retrograde biliary intervention failures (12%) before introduction of endoscopy and no failures (0 of 38 [0%]) subsequently (P = .06). Endoscopy or cholangioscopy was performed in 19 procedures by interventional radiologists. Retrograde biliary interventions included diagnostic cholangiography (n = 26), cholangioplasty (n = 25), stent placement (n = 29), stent retrieval (n = 25), and biliary drainage catheter placement (n = 5). No procedure-related mortality occurred. There was 1 major complication (duodenal perforation) (1.6%) and 12 minor complications (19%). In the 9 patients undergoing therapeutic interventions for biliary strictures, there was a significant decrease in median alkaline phosphatase (288.5 to 174.5 U/L; P = .03). There was a trend toward decrease in median bilirubin levels (1.7 to 1 mg/dL; P = .06) at 1 month post-intervention. CONCLUSIONS The modified Hutson loop provided interventional radiologists a safe and effective alternative access to manage biliary complications in patients with biliary-enteric anastomoses. Introduction of the endoscope in interventional radiology has improved the success rate of these procedures.
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Affiliation(s)
- Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois.
| | - Pouya Entezari
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Elliott Russell
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Daniela Ladner
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, Illinois
| | - Nitin Katariya
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, Illinois
| | - Juan Carlos Caicedo
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, Illinois
| | - Justin Boike
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Rajesh Keswani
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Abdul Aziz Aadam
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
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6
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Kim D, Bolus C, Iqbal SI, Davison BD, Ahari HK, Flacke S, Molgaard CP. Percutaneous Transjejunal Biliary Access in 60 Patients with Bilioenteric Anastomoses. J Vasc Interv Radiol 2018; 30:76-81.e1. [PMID: 30316675 DOI: 10.1016/j.jvir.2018.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To determine success and complication rates of percutaneous transjejunal biliary access (PTJBA) in patients with bilioenteric anastomoses. MATERIALS AND METHODS In a single-center, retrospective study, 169 PTJBA procedures were performed over a 13.8-y period in 60 subjects (47 male; mean age, 54.5 y). Indications for biliary interventions were cholangitis (137 cases, 45 subjects) or hyperbilirubinemia (32 cases, 18 subjects). All patients had antecolic bilioenteric anastomoses without surgical fixation to the peritoneum (liver transplantation with hepaticojejunostomy, n = 37; hepatectomy with hepaticojejunostomy, n = 8; hepaticojejunostomy only, n = 12; pancreaticoduodenectomy, n = 3). RESULTS Initial PTJBA was successful in 140 cases (82.8%) in 35 subjects (58.3%). Twenty-one additional PTJBAs (12.4%) in 18 subjects (30.0%) were performed secondarily following a conventional transhepatic approach. Radiographic markers on the Roux-en-Y limb (P = .14, odds ratio [OR] = 2.98) or preprocedural imaging (P = .13, OR = 10.00) did not increase the odds of successful PTJBA. There were 7 major complications (4.3%) in 6 patients (10.0%) requiring hospitalization longer than 5 d, and 37 minor complications (23.0%) in 19 patients (31.7%). No procedure-related mortality was observed. Minor and major complication rates were not affected by time between bilioenteric anastomosis creation and PTJBA (P = .70, OR = 1.00; P = .62, OR = 1.00), longer dwell time of a transjejunal drain (P = .68, OR = 1.02; P = .49, OR = 0.71), or access size (P = .40, OR = 0.85; P = .23, OR = 0.59). CONCLUSIONS PTJBA is a relatively safe technique with a high success rate in patients with bilioenteric loops that are not surgically fixed to the peritoneum.
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Affiliation(s)
- DaeHee Kim
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805.
| | - Christopher Bolus
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Shams I Iqbal
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Brian D Davison
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Heideh K Ahari
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Sebastian Flacke
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Christopher P Molgaard
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
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