Percutaneous rendezvous technique for the management of a bile duct injury

Unlocking the enigma: Combined percutaneous-transhepatic and endoscopic strategies for retrieval of severed Dormia basket in choledocholithiasis. A case report and literature review

Choledocholithiasis, characterized by the presence of stones in the common bile duct, poses significant challenges in clinical management, particularly when the stones are massive. While endoscopic methods are often effective in stone removal, complications such as the impaction of foreign bodies like Dormia baskets can occur. These complications may necessitate alternative approaches, including surgical intervention, highlighting the importance of exploring innovative interventional techniques. We report on an 89-year-old patient presenting with massive choledocholithiasis, involving complete filling of the intra- and extrahepatic bile duct system with large stones up to a maximum of 2 cm. The patient underwent interventional removal of a Dormia basket (3.5Fr. Boston Scientific, USA) impacted in the common bile duct. This procedure proved challenging due to the metallic end marker of the basket perforating through the wall of the distal common bile duct, rendering it fixed. Given the complexity of the case, a parallel approach combining percutaneous transhepatic cholangiography and drainage with simultaneous endoscopy was employed to successfully extract the fixed Dormia basket. In cases of severe choledocholithiasis complicated by the impaction of foreign bodies such as Dormia baskets, innovative interventional strategies are crucial for successful management. Our case highlights the effectiveness of a parallel approach involving percutaneous transhepatic cholangiography and drainage alongside simultaneous endoscopy in safely removing the fixed foreign body from the common bile duct. This multidisciplinary approach not only offers a viable alternative to surgical intervention but also underscores the importance of collaboration between interventional radiologists and endoscopists in optimizing patient outcomes in complex biliary interventions.

Percutaneous Biliary Rendez-Vous to Treat Complete Hepatic-Jejunal Anastomosis Dehiscence after Duodeno-Cephalo-Pancreasectomy

Hepaticojejunostomy is an essential component of many surgical procedures, including pancreaticoduodenectomy. Biliary leaks after HJS represent a major complication leading to relevant clinical problems: the postoperative mortality rate could reach 70% for surgical re-intervention, whereas endoscopic management is technically difficult due to the postoperative anatomy. Interventional Radiology plays a pivotal role for these patients. The case of a percutaneous biliary rendez-vous procedure performed to treat an HJA dehiscence after duodeno-cephalo-pancreasectomy is presented, which is successfully guaranteed to avoid a new surgical approach.

Totally percutaneous rendezvous technique for the treatment of complete biliary obstruction after liver transplant

Biliary complications, including biliary stricture and obstruction, remain a major cause of morbidity and mortality after living donor liver transplantation. In these patients the biliary system may not be accessible by endoscopic approach due to Roux-en-Y hepaticojejunostomy, and a percutaneous approach may be considered to avoid surgical interventions. When there is complete biliary obstruction, the conventional percutaneous approaches may not be successful to cross the hepaticojejunostomy anastomosis. In this study, a totally percutaneous rendezvous technique was used to create a neo-biliary-enteric tract using a trans-biliary Rosch-Uchida needle in a patient with complete biliary obstruction and Roux-en-Y anastomosis after a split liver transplant. A biodegradable stent was placed after recanalization with long-term patency on follow up.

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.