The Role of the Interventional Radiologist in Bile Leak Diagnosis and Management

2021 ◽  
Vol 38 (03) ◽  
pp. 309-320
Author(s):  
Yuli Zhu ◽  
Ryan Hickey
Keyword(s):  
Bile Duct ◽  
Bile Leak ◽  
Biliary Tree ◽  
Vital Role ◽  
Trauma Patients ◽  
Diagnosis And Management ◽  
Nonsurgical Management ◽  
Fluid Collections ◽  
Bile Leaks

AbstractBile 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.

Fifteen-Year Single-Center Experience of Biliary Complications in Liver Trauma Patients: Changes in the Management of Posttraumatic Bile Leak

2020 ◽  
Author(s):  
Stephen Stonelake ◽  
Sana Ali ◽  
Benjamin Pinkey ◽  
Evelyn Ong ◽  
Ravindar Anbarasan ◽  
...  
Keyword(s):  
Median Time ◽  
Bile Leak ◽  
Liver Trauma ◽  
Trauma Patients ◽  
Hepatobiliary Scintigraphy ◽  
Line Treatment ◽  
First Line ◽  
Leak Management ◽  
Bile Leaks ◽  
First Line Treatment

Abstract Introduction Management of posttraumatic bile leak has evolved over time in our unit, from endoscopic retrograde cholangiopancreatography (ERCP) stenting to intraperitoneal drainage (IPD) alone as first-line treatment for intraperitoneal bile leak. Materials and Methods Retrospective review of liver trauma patients from 2002 to 2017. Demographics, time and mode of diagnosis of bile leak, management, and outcome were analyzed of the box plot. Results In 118 patients, there were 28 traumatic bile leaks. Eighteen were free intraperitoneal and 10 were localized bilomas. The median time of diagnosis was 6 days following injury. The modes of diagnosis were preemptive hepatobiliary scintigraphy (18), computed tomography (CT) or ultrasound (7), and laparotomy (3). Free intraperitoneal biliary leak management included 11 IPD alone, 3 IPD plus ERCP, 2 IPD plus transcystic biliary stent (TBS), 1 operative cholangiogram, and 1 no intervention. Median time of IPD duration was 7 days (4–95) in IPD alone versus 14 days (6–40) in IPD + ERCP/TBS (p = 0.3). Median inpatient length of stay was 13 days (8–44) in IPD alone versus 12 days (8–22) in IPD + ERCP/TBS (p = 0.4). Conclusion Placement of IPD alone, as first-line treatment, is safe and effective in the management of intraperitoneal bile leaks, avoiding the costs and potential complications of ERCP.

scholarly journals Leakage Via Aberrant Bile Duct Due to Cholangiocarcinoma

HPB Surgery ◽  
1998 ◽  
Vol 11 (2) ◽  
pp. 125-128 ◽  
Author(s):  
R. Stanton ◽  
P. I. Craig ◽  
J. O. Jorgensen ◽  
D. L. Morris
Keyword(s):  
Bile Duct ◽  
Hepatic Duct ◽  
Open Cholecystectomy ◽  
Bile Leak ◽  
Biliary Tree ◽  
Unusual Presentation ◽  
Subsequent Investigation ◽  
The Right ◽  
Aberrant Bile Duct

The case of a male who had an open cholecystectomy complicated by presistent bile leak from an aberrant bile duct is presented. The persistence and volume of bile leak resulted in subsequent investigation of the biliary tree which demonstrated a cholangiocarcinoma of the right hepatic duct. This case is presented as an unusual presentation of cholangiocarcinoma and to highlight the value of modern techniques in imaging the biliary tree.

scholarly journals Bile Duct Leaks from the Intrahepatic Biliary Tree: A Review of Its Etiology, Incidence, and Management

HPB Surgery ◽  
2012 ◽  
Vol 2012 ◽  
pp. 1-9 ◽  
Author(s):  
Sorabh Kapoor ◽  
Samiran Nundy
Keyword(s):  
Liver Resection ◽  
Bile Duct ◽  
Liver Abscess ◽  
Biliary Tree ◽  
Tumor Ablation ◽  
Hepatic Surgery ◽  
Biliary Decompression ◽  
Enteric Drainage ◽  
Bile Leaks

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.

Primary Closure and Rate of Bile Leak following Laparoscopic Common Bile Duct Exploration via Choledochotomy

2015 ◽  
Vol 32 (1) ◽  
pp. 1-8 ◽  
Author(s):  
Jie Hua ◽  
Shengping Lin ◽  
Daohai Qian ◽  
Zhigang He ◽  
Ti Zhang ◽  
...  
Keyword(s):  
Bile Duct ◽  
Common Bile Duct ◽  
Primary Closure ◽  
Bile Leak ◽  
Significant Risk ◽  
Biliary Tree ◽  
Common Bile Duct Exploration ◽  
T Tube ◽  
Duct Stricture

Background: Choledocholithiasis is traditionally managed by endoscopic retrograde cholangiopancreatography or T-tube insertion following common bile duct exploration. This study examined the efficacy and safety of primary duct closure following laparoscopic common bile duct exploration (LCBDE) via choledochotomy. Methods: Between September 2011 and September 2013, 157 consecutive patients underwent LCBDE via choledochotomy. Results: Of 157 LCBDE procedures, 138 (87.9%) were successfully completed with primary closure of the choledochotomy. Eight patients (5.1%) underwent closure with T-tube drainage after choledochotomy and 11 patients (7.0%) were converted to open surgery. The biliary tree was free of stones at the end of surgery in 154 patients (98.1%). Postoperative bile leak occurred in 6 patients (3.8%). The median follow-up period was 18 (2-33) months, with no evidence of further bile duct stones or bile duct stricture in any patients. Univariable analysis revealed that successful duct clearance (p = 0.010) and diameter of the common bile duct (p < 0.001) were two significant risk factors for bile leak. Conclusions: Primary duct closure following LCBDE is effective and safe for the management of choledocholithiasis. The postoperative bile leak rate may be low in skilled laparoscopic surgeons with a careful selection of patients.

scholarly journals Botryoid rhabdomyosarcoma of common bile duct: Diagnostic imaging features of an unusual pathology: Case report and review

2016 ◽  
Vol 02 (01) ◽  
pp. 049-052
Author(s):  
Abhishek Mane ◽  
Ashish Verma ◽  
Amrita Kar ◽  
Ritu Ojha ◽  
Ram Shukla ◽  
...  
Keyword(s):  
Case Report ◽  
Bile Duct ◽  
Common Bile Duct ◽  
Choledochal Cyst ◽  
Preoperative Diagnosis ◽  
Preoperative Staging ◽  
Biliary Tree ◽  
Vital Role ◽  
Imaging Features ◽  
Benign Condition

AbstractRhabdomyosarcoma (RMS) is the most common tumor of biliary tree in childhood. Biliary tree is an uncommon site for RMS to occur, accounting for about 1% of all pediatric RMS. A preoperative diagnosis is not difficult with background knowledge of its imaging features. The diagnosis of this malignancy is especially important as it many times mimics a more common and benign condition of choledochal cyst. The key to diagnosis is to distinguish solid component of the tumor from organized sludge seen in choledochal cyst. Imaging plays a vital role for preoperative staging as well.

scholarly journals Bile Duct Injury in Children: Is There a Role for Early Endoscopic Retrograde Cholangiopancreatography?

2018 ◽  
Vol 04 (03) ◽  
pp. e119-e122 ◽  
Author(s):  
Akram Aljahdali ◽  
James Murphy
Keyword(s):  
Bile Duct ◽  
Endoscopic Retrograde Cholangiopancreatography ◽  
Pediatric Patients ◽  
Bile Leak ◽  
Standard Of Care ◽  
Bile Peritonitis ◽  
Endoscopic Retrograde ◽  
Liver Injuries ◽  
Bile Duct Stent ◽  
Bile Leaks

Introduction Liver injury is common among pediatric abdominal trauma. Nonoperative management is the standard of care in isolated stable liver injuries. Bile leak is not an uncommon complication in moderate- and high-grade injuries. Case series Three pediatric patients (age: 10–15 years) suffered grade IV liver injuries secondary to blunt abdominal trauma. All developed significant bile leak treated nonoperatively with endoscopic retrograde cholangiopancreatography (ERCP), and patients 1 and 2 were treated with bile duct stent alone. Patient 3 required laparotomy for bile peritonitis and abdominal compartment syndrome followed by interval ERCP and bile duct stent. Conclusion Traumatic bile leaks if not recognized and managed early can result in significant morbidity. This paper describes the presentation and treatment of three pediatric patients with blunt liver trauma complicated by significant bile leaks that were managed successfully with ERCP and bile duct stent. This paper demonstrates the importance of early detection of bile leak to prevent bile peritonitis. Abdominal imaging 4 to 5 days postinjury can help in detecting bile accumulation. We believe that ERCP and bile duct stent are becoming the standard of care in diagnosing and treating traumatic bile leak. This paper confirms the safety and feasibility of this technique in the pediatric population.

scholarly journals Necessity of a Repeat Cholangiogram During Biliary Stent Removal after Postcholecystectomy Bile Leak

2012 ◽  
Vol 26 (10) ◽  
pp. 701-704 ◽  
Author(s):  
Vishal Jain ◽  
Nathan Yeasted ◽  
Nakechand Pooran
Keyword(s):  
Bile Duct ◽  
Common Bile Duct ◽  
Hepatic Duct ◽  
Bile Leak ◽  
Final Analysis ◽  
Biliary Stent ◽  
Common Hepatic Duct ◽  
Open Approach ◽  
Stent Removal ◽  
Bile Leaks

PURPOSE: To assess the need for repeat endoscopic retrograde cholangiography (ERC) in patients undergoing biliary stent removal after management of postcholecystectomy bile leak.METHODS: A retrospective analysis of the Clinical Outcomes Research Initiative endoscopy database at PennState Milton S Hershey Medical Center (Hershey, Pennsylvania, USA) identified all patients referred for ERC with an indication of postcholecystectomy bile leak from January 2001 to June 2010. Baseline demographics, location of bile leak, size of biliary stent placed, duration of stenting, bile leak persistence, and the presence of stone, sludge or strictures on repeat ERC were analyzed.RESULTS: A total of 81 patients underwent ERC for management of bile leaks after cholecystectomy. One patient was excluded due to a complete transection of the common bile duct necessitating immediate surgical intervention. Fourteen (17.5%) patients underwent open cholecystectomy, 46 (57.5%) underwent laparoscopic procedures and 10 (12.5%) procedures were converted from a laparoscopic to an open approach intraoperatively. Of the 80 patients, 47 (58.7 %) had a cystic duct leak, 11 (13.7 %) had a right hepatic duct leak, 11 (13.7%) had a common bile duct leak, five (6.2%) had a gallbladder fossa leak, four (5%) had a common hepatic duct leak and the remaining two (2.5%) had a left hepatic duct leak. All 80 patients underwent biliary stenting as part of management for their bile leak. Fifty-seven of the 80 patients (71.2%) had a 10 Fr stent placed, with the remainder undergoing placement of a 7 Fr stent. Seventy-five (93.7%) patients underwent biliary sphincterotomy during the initial ERC. Sixty-nine patients underwent repeat ERC after a mean duration of 8.2 weeks (range 0.4 to 18.5 weeks). Eleven patients had no reviewable records regarding a repeat procedure performed for stent removal. Three patients required an early repeat ERC due to suspicion of cholangitis and, hence, were excluded from the final analysis. Of the 66 patients included in the final analysis, 61 (92.4%) had resolution of their bile leak on repeat ERC. All patients had resolution of their bile leak by the third ERC. Fifteen patients (22.7%) had an abnormality on repeat cholangiography (persistent leak in four, stones in three, sludge in seven, and a combination of leak and stone in one) that required further endoscopic intervention including balloon sweep or additional stenting.CONCLUSION: Although the majority of postcholecystectomy bile leaks resolve after biliary stent placement, a sizeable percentage (22.7%) of patients had abnormalities on subsequent cholangiograms that required further intervention. These findings suggest the need for a repeat ERC at the time of biliary stent removal in the management of postcholecystectomy bile leaks.

scholarly journals Multidisciplinary Care of Patients with Intrahepatic Cholangiocarcinoma: Updates in Management

2015 ◽  
Vol 2015 ◽  
pp. 1-14 ◽  
Author(s):  
Kelly J. Lafaro ◽  
David Cosgrove ◽  
Jean-Francois H. Geschwind ◽  
Ihab Kamel ◽  
Joseph M. Herman ◽  
...  
Keyword(s):  
Bile Duct ◽  
Bile Ducts ◽  
Multidisciplinary Care ◽  
Biliary Tree ◽  
The United States ◽  
Gastrointestinal Cancers ◽  
The Past ◽  
Nonsurgical Management ◽  
Duct Epithelium ◽  
Bile Duct Epithelium

Cholangiocarcinoma is a highly fatal primary cancer of the bile ducts which arises from malignant transformation of bile duct epithelium. While being an uncommon malignancy with an annual incidence in the United States of 5000 new cases, the incidence has been increasing over the past 30 years and comprises 3% of all gastrointestinal cancers. Cholangiocarcinoma can be classified into intrahepatic (ICC) and extrahepatic (including hilar and distal bile duct) according to its anatomic location within the biliary tree with respect to the liver. This paper reviews the management of ICC, focusing on the epidemiology, risk factors, diagnosis, and surgical and nonsurgical management.

Treatment of Malignant Bile Duct Obstruction: What the Interventional Radiologist Needs to Know

2021 ◽  
Vol 38 (03) ◽  
pp. 300-308
Author(s):  
Juan C. Camacho ◽  
Lynn A. Brody ◽  
Anne M. Covey
Keyword(s):  
Bile Duct ◽  
Biliary Drainage ◽  
Bile Leak ◽  
Biliary Tree ◽  
Bile Duct Obstruction ◽  
Cross Sectional ◽  
Advanced Malignancy ◽  
Duct Obstruction ◽  
Extrinsic Compression ◽  
Malignant Bile Duct Obstruction

AbstractManagement of malignant bile duct obstruction is both a clinically important and technically challenging aspect of caring for patients with advanced malignancy. Bile duct obstruction can be caused by extrinsic compression, intrinsic tumor/stone/debris, or by biliary ischemia, inflammation, and sclerosis. Common indications for biliary intervention include lowering the serum bilirubin level for chemotherapy, ameliorating pruritus, treating cholangitis or bile leak, and providing access for bile duct biopsy or other adjuvant therapies. In some institutions, biliary drainage may also be considered prior to hepatic or pancreatic resection. Prior to undertaking biliary intervention, it is essential to have high-quality cross-sectional imaging to determine the level of obstruction, the presence of filling defects or atrophy, and status of the portal vein. High bile duct obstruction, which we consider to be obstruction above, at, or just below the confluence (Bismuth classifications IV, III, II, and some I), is optimally managed percutaneously rather than endoscopically because interventional radiologists can target specific ducts for drainage and can typically avoid introducing enteric contents into isolated undrained bile ducts. Options for biliary drainage include external or internal/external catheters and stents. In the setting of high obstruction, placement of a catheter or stent above the ampulla, preserving the function of the sphincter of Oddi, may lower the risk of future cholangitis by preventing enteric contamination of the biliary tree. Placement of a primary suprapapillary stent without a catheter, when possible, is the procedure most likely to keep the biliary tree sterile.

scholarly journals Endoscopic Fistulotomy – ‘The Suprapapillary Punch’: A Method of Access to the Bile Duct during ERCP

1994 ◽  
Vol 8 (1) ◽  
pp. 33-35
Author(s):  
Noel B Hershfield
Keyword(s):  
Bile Duct ◽  
Common Bile Duct ◽  
Endoscopic Retrograde Cholangiopancreatography ◽  
Biliary Tree ◽  
Usual Method ◽  
Endoscopic Retrograde ◽  
The Common ◽  
A Minor ◽  
Endoscopic Fistulotomy

Endoscopic retrograde cholangiopancreatography (ERCP) is established as the method of choice to investigate the biliary tree when obstruction is suspected. On rare occasions, the papilla cannot be entered because of anatomical or pathological abnormalities. This report describes endoscopic fistulotomy or the suprapapillary punch that has been carried out at the Foothills Hospital in Calgary, Alberta, on 30 of 623 patients referred for ERCP for conditions causing obstruction of the common bile duct or suspected obstruction of the common bile duct. The following communication also describes the method of suprapapillary punch or endoscopic fistulotomy. Results have been excellent with only one complication, a minor attack of pancreatitis after the procedure. In summary, the suprapapillary punch or fistulotomy is a safe and useful method for entering the common bile duct when access by the usual method is impossible.

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