Cardiovasc Intervent Radiol (2007) 30:761–764 DOI 10.1007/s00270-007-9078-6
TECHNICAL NOTE
Percutaneous Therapy for Anastomotic Bile Leak in Liver-Transplant Patients with Nondilated Bile Ducts Cuneyt Aytekin Æ Fatih Boyvat Æ Ali Harman Æ Umut Ozyer Æ Hamdi Karakayalı Æ Mehmet Haberal
Received: 12 February 2007 / Revised: 12 February 2007 / Accepted: 1 April 2007 / Published online: 29 May 2007 Ó Springer Science+Business Media, LLC 2007
Bile leaks remain a significant cause of postoperative morbidity in 4.9% to 26.6% of liver transplant recipients [1–4] and can be managed surgically or nonsurgically. Most leaks can be treated with interventional radiologic techniques. However, in cases with bile ducts that are decompressed because of massive leakage (mostly anastomotic), percutaneous access into a peripheral bile duct is usually difficult. In the cases presented here, we performed retrograde catheterization of a peripheral bile duct to make the percutaneous procedure easier to perform and less traumatic for the patient.
Case Reports Case 1 Forty-nine days after orthotopic liver transplantation, a 59year-old man presented with abdominal pain and tenderness. A large perihepatic fluid collection, or biloma, was found on ultrasound examination. After bile-stained fluid aspiration, percutaneous drainage of the perihepatic biloma was performed under ultrasonographic guidance. Following this procedure, output through the drainage catheter was high (>200 ml per 24 h). Two weeks later, drip-infusion pouchography obtained via the drainage catheter showed a communication between the biloma and the biliary system at the C. Aytekin (&) F. Boyvat A. Harman U. Ozyer H. Karakayalı M. Haberal Department of Radiology and General Surgery, Baskent University Hospital, Fevzi Cakmak cad. 10, sok. No. 45, Bahcelievler, Ankara 06490, Turkey e-mail:
[email protected]
site of the surgical anastomosis. Endoscopic management was our first treatment option, but it failed in crossing the anastomosis. We decided to perform percutaneous transhepatic biliary drainage. Because the leak had caused decompression of bile ducts, we decided to use our biloma access to make the percutaneous bile duct puncture easier. The procedure was performed after antibiotic prophylaxis. After initiation of intravenous (IV) sedation and local anesthesia, the drainage catheter was exchanged for a 6-F introducer sheath (Arrow International, Inc., Reading, PA, USA) positioned over a guide wire. A 5-F catheter (SOS OMNI; AngioDynamics, Queensbury, NY, USA) was inserted from the biloma pouch and passed through the disrupted anastomosis. Then a microcatheter (fast tracker; Boston Scientific, Natick, MA, USA) was coaxially inserted into a peripheral bile duct available for percutaneous access (Fig. 1), and contrast material was injected through the microcatheter to opacify and distend this duct. Under fluoroscopy and using a 21-gauge needle (AccuStick Introducer System; Boston Scientific), a percutaneous puncture was made in the same duct. After the percutaneous needle puncture was made in the duct, a coaxial dilator (AccuStick Introducer System; Boston Scientific) was placed over an 0.018-in. Nitinol guide wire, then a 0.035-in. glide wire (Terumo, Tokyo) was advanced through the dilator, and a 6-F introducer (Terumo) was inserted into the duct over the wire. A 5-F catheter (Terumo) with a guide wire was used to cross the leak site. Then, over a stiff guide wire (Amplatz Super Stiff Guide Wire; Boston Scientific), a 10-F biliary drainage catheter (Flexima; Boston Scientific) with multiple side holes positioned on both sides of the anastomosis was placed to divert bile away from the defect. The leak had disappeared after 57 days of percutaneous biliary drainage.
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Fig. 1 Case 1. A Pouchography via a 6-F introducer sheath positioned in the biloma (asterisk) shows a communication between the biliary tree and the biloma caused by anastomotic defect. B By way of a 5-F catheter passed through the disrupted anastomosis, a microcatheter (arrow) was coaxially inserted into a bile duct. C A percutaneous puncture was made into the same duct (arrow), which had been distended by contrast-material injection through the microcatheter. D A 10-F internal-external biliary drainage catheter was inserted into the biliary system across the anastomosis. E A cholangiogram obtained 35 days after the biliary drainage shows the intact anastomosis
Case 2 A 25-year-old man presented with marked bile drainage from surgical drains 16 days after orthotopic liver transplantation. A T-tube cholangiogram showed bile leakage from a choledochocholedochostomy anastomosis. (In this case, two ducts had been joined before duct-to-duct anastomosis during transplantation.) After endoscopic stenting failed, we planned percutaneous intervention. As ultrasonography indicated no dilated bile ducts, we used the surgical T-tube access to facilitate percutaneous intervention. After antibiotic prophylaxis and initiation of IV sedation and local anesthesia, the T tube was exchanged for a 6-F introducer sheath (Arrow International, Inc., Reading, PA,
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USA) over a 0.035-in. guide wire (Terumo). After insertion of a safety guide wire into the distal common bile duct, the defective anastomosis was crossed in a retrograde fashion using a 5-F catheter (Terumo) over the guide wire. After catheterization of a selected peripheral bile duct, contrast material was injected through the catheter to distend the bile duct and make it fluoroscopically visible. However, the duct emptied rapidly after the injection because of the large anastomotic defect. So the catheter was exchanged for a 6-F balloon occlusion catheter (Arrow International, Inc.), and after the balloon was inflated, contrast material was injected through the lumen of the catheter (Fig. 2). When the duct was filled and distended, percutaneous transhepatic puncture was easily performed using a
C. Aytekin et al.: Percutaneous Therapy for Anastomotic Bile Leak
21-guage needle (AccuStick Introducer System; Boston Scientific) in the same peripheral bile duct. The procedure was completed in the same fashion as described for Case 1 and repeated for the second duct. Finally, two 10-F internal-external biliary drainage catheters (Flexima; Boston Scientific) were left in the biliary system. Ninety-six days after the percutaneous procedure, the leak was resolved and the catheters were removed.
Discussion Bile leaks usually occur in the first weeks after transplantation, most often at the surgical anastomosis or cut edge [5]. Treatment options should be selected according to the type of leak. Although percutaneous drainage of a biloma is usually sufficient for self-limited leaks, in cases with ongoing leaks, the primary goal is to divert bile away from the leak site. Surgical revision has been the preferred treatment method for massive leaks. However, in clinically stable patients, an anastomotic leak can be successfully managed without surgery [6–8]. In cases with a dilated biliary system, especially in patients with coexistent stricture, percutaneous, transhepatic biliary access can easily be achieved under ultrasonographic or fluoroscopic guidance. However, with
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large anastomotic defects, bile ducts are usually markedly decompressed because of massive leakage. This makes percutaneous access into the biliary tree very difficult. Because the peripheral bile ducts are decompressed, many capsule punctures and many passes through the liver under fluoroscopy may be required [9]. An endoscopic approach is the preferred method in such cases [10]. However, cannulation of bile ducts proximal to the leak site can be unsuccessful. In addition, an endoscopic approach is not feasible for patients with a hepaticojejunostomy anastomosis. For percutaneous biliary access in cases with a nondilated system, one of the most common techniques is to puncture main bile ducts near the hilum and then fill the whole biliary tract with contrast material, including peripheral bile ducts available for access [11]. But this procedure carries a risk of damage to hilar vascular structures [12]. In addition, with massive leaks, it might be impossible to fill the peripheral bile ducts sufficiently. For liver transplant recipients with leakage, the first step in both diagnosis and treatment is ultrasonography-guided percutaneous drainage of the biloma. If the patient’s clinical status is stable a few days after the drainage of this bile collection, radiograms can be taken after injection of contrast material through the drainage catheter (drip-infusion pouchography) and usually show communication of
Fig. 2 Case 2. A A T-tube cholangiogram shows anastomotic biliary leakage (arrow). B A balloon occlusion catheter was inserted through the T tube and advanced into a bile duct. Contrast material was injected into the duct after the balloon was inflated (arrow). C A percutaneous needle puncture was made with a 21-gauge needle (arrow). D The procedure was repeated for the second duct, and two 10-F internal-external biliary drainage catheters were inserted into the biliary system. A cholangiogram taken 3 months after the biliary drainage shows no leak
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the biloma with the biliary system. Injecting contrast material into the biliary tract makes peripheral bile ducts fluoroscopically visible for percutaneous access. If the patient has a T-tube catheter in place, a T-tube cholangiogram can be used for the same purpose. However, when the defect is large, contrast material can be washed rapidly out of the biliary tree. In such cases, the puncture can be facilitated by the retrograde passage of a microcatheter from the biloma via the drainage catheter or T-tube tract. The microcatheter can be advanced into an ideal peripheral bile duct for opacification and distention of the duct by contrast-material injection. If the duct is emptying rapidly after injection, an occlusion balloon catheter can be used to prevent duct decompression. After occlusion of the proximal part of the duct by the inflated balloon, a peripheral bile duct can be distended with contrast material. Alternatively a snare can also be used to make the percutaneous puncture easier [13]. In conclusion, percutaneous interventional procedures are effective therapeutic alternatives for the treatment of bile leaks following liver transplantation. Although technically demanding, retrograde catheterization techniques make these procedures less traumatic in patients with serious biliary anastomotic leaks.
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C. Aytekin et al.: Percutaneous Therapy for Anastomotic Bile Leak 2. Ramacciato G, Varotti G, Quintini C, et al. (2006) Impact of biliary complications in right lobe living donor liver transplantation. Transpl Int 19(2):122–127 3. Qian YB, Liu CL, Lo CM, Fan ST (2004) Risk factors for biliary complications after liver transplantation. Arch Surg 139(10):1101–1105 4. Testa G, Malago M, Valentin-Gamazo C, Lindell G, Broelsch CE (2000) Biliary anastomosis in living related liver transplantation using the right liver lobe: techniques and complications. Liver Transpl 6(6):710–714 5. Gondolessi GE, Varotti G, Florman SS, et al. (2004) Biliary complications in 96 consecutive right lobe living donor transplant recipients. Transplantation 77:1842–1848 6. Chang JM, Lee JM, Suh KS, et al. (2005) Biliary complications in living donor liver transplantation: imaging findings and the roles of interventional procedures. CardioVasc Interv Radiol 28(6):756–767 7. Ernst O, Sergent G, Mizrahi D, Delemazure O, L’Hermine´ C (1999) Biliary leaks: treatment by means of percutaneous transhepatic biliary drainage. Radiology 211(2):345–348 8. Osorio RW, Freise CE, Stock PG, et al. (1993) Nonoperative management of biliary leaks after orthotopic liver transplantation. Transplantation 55(5):1074–1087 9. Funaki B, Zaleski GX, Straus CA, et al. (1999) Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts. AJR 173(6):1541–1544 10. Thuluvath PJ, Atassi T, Lee J (2003) An endoscopic approach to biliary complications following orthotopic liver transplantation. Liver Int 23(3):156–162 11. Cozzi G, Severini A, Civelli E, et al. (2006) Percutaneous transhepatic biliary drainage in the management of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts. CardioVasc Interv Radiol 29(3):380–388 12. L’Hermine C, Ernst O, Delemazure O, Sergent G (1996) Arterial complications of percutaneous transhepatic biliary drainage. CardioVasc Interv Radiol 19(3):160–164 13. Harris VJ, Kopecky KK, Harman JT, Crist DW (1993) Percutaneous drainage of the nondilated biliary system. J Vasc Interv Radiol 4(5):591–595
