Hemobilia after percutaneous transhepatic biliary drainage: treatment with transcatheter embolotherapy

Transcatheter arterial embolization for massive hemobilia with N-butyl cyanoacrylate (NBCA) Glubran 2

BACKGROUND

Massive hemobilia is a life-threatening condition and therapeutic challenge. Few studies have demonstrated the use of N-butyl cyanoacrylate (NBCA) for massive hemobilia.

PURPOSE

To investigate the efficacy and safety of transcatheter arterial embolization (TAE) using NBCA Glubran 2 for massive hemobilia.

MATERIAL AND METHODS

Between January 2012 and December 2019, the data of 26 patients (mean age 63.4 ± 12.6 years) with massive hemobilia were retrospectively evaluated for TAE using NBCA. The patients' baseline characteristics, severities of hemobilia, and imaging findings were collected. Emergent TAE was performed using 1:2-1:4 mixtures of NBCA and ethiodized oil. Technical success, clinical success, procedure-related complications, and follow-up outcomes were assessed.

RESULTS

Pre-procedure arteriography demonstrated injuries to the right hepatic artery (n = 24) and cystic artery (n = 2). Initial coil embolization distal to the lesions was required in 5 (19.2%) patients to control high blood flow and prevent end-organ damage. After a mean treatment time of 11.2 ± 5.3 min, technical success was achieved in 100% of the patients without non-target embolization and catheter adhesion. Clinical success was achieved in 25 (96.2%) patients. Major complications were noted in 1 (3.8%) patient with gallbladder necrosis. During a median follow-up time of 16.5 months (range 3-24 months), two patients died due to carcinomas, whereas none of the patients experienced recurrent hemobilia, embolic material migration, or post-embolization complications.

CONCLUSION

NBCA embolization for massive hemobilia is associated with rapid and effective hemostasis, as well as few major complications. This treatment modality may be a promising alternative to coil embolization.

The Dramatic Haemostatic Effect of Covered Self-expandable Metallic Stents for Duodenal and Biliary Bleeding

Bilio-duodenal bleeding, such as post-endoscopic sphincterotomy (EST) bleeding, common bile duct (CBD) bleeding after endoscopic retrograde cholangiopancreatography (ERCP), and duodenal bleeding due to malignant tumour invasion, can sometimes become severe. Six cases of refractory bilio-duodenal bleeding were stanched via covered self-expandable metallic stent (CSEMS) insertion, even though three of the patients had a history of gastrectomy. The dumbbell-shaped CSEMS was useful for managing post-EST bleeding. Additional duodenal CSEMS insertion was useful for the patient who had previously undergone uncovered SEMS insertion, and no migration of the CSEMS was observed. CSEMS insertion was useful for treating refractory bilio-duodenal haemorrhaging.

Diagnosis and management of hemorrhagic complications of percutaneous transhepatic biliary drainage: a primer for residents

Hemorrhagic complications are uncommon after percutaneous transhepatic biliary drainage. The presenting features include bleeding through or around the drainage catheter, hematemesis or melena. Diagnosis requires cholangiography, CT angiography or conventional angiography. Minor venous hemorrhage is managed by catheter repositioning, clamping or upgrading to a larger bore catheter. Major vascular injuries require percutaneous or endovascular procedures like embolization or stenting. A complete knowledge of these complications will direct the interventional radiologist to take adequate precautions to reduce their incidence and necessary steps in their management. This review presents and discusses various hemorrhagic complications occurring after percutaneous transhepatic biliary drainage along with their treatment options and suggests a detailed algorithm.

Hemobilia as a Complication of Transhepatic Percutaneous Biliary Drainage: a Rare Indication for Laparoscopic Common Bile Duct Exploration

BACKGROUND

Hemobilia is the presence of blood in the biliary tree and is a frequent complication after percutaneous transhepatic biliary drainage (PTBD).¹ Most of these episodes are self-limited; nevertheless, in less than 5% of cases, hemobilia is clinically significant, requiring an intervention (hepatic artery embolization, stenting, or percutaneous thrombin injection).^2,3 Adequate treatment requires control of hemorrhage and restoration of bile flow. Surgery is the last resort and is indicated when the other modalities fail.

METHODS

A 65-year-old man with multiple comorbidities was admitted with cholangitis. The patient underwent PTBD (Figure 1) but had persistent cholestasis. Thus, he underwent endoscopic cholangiopancreatography (ERCP), in which a plastic stent was misplaced within the common bile duct (CBD) and could not be removed (Figure 2). Afterwards, as the patient had persistently high bilirubin levels and the previously placed stent was malpositioned, the decision was made to proceed with laparoscopic cholecystectomy and CBD exploration.

RESULTS

The operation was performed with choledocoscope guidance, and the CBD was closed over a T-tube. The operative time was 280 min. Postoperative course was uneventful; the T-tube was clamped 1 week after discharge. Four weeks postoperatively, the T-tube cholangiogram showed a patent extrahepatic biliary tree with no filling defects (Figure 3). The T-tube was then removed.

CONCLUSIONS

Biliary obstruction secondary to hemobilia is a rare occurrence after PTBD. Surgical CBD exploration is required when conservative management and endoscopic treatment fail and can be done successfully through a minimally invasive approach.

EUS-guided biliary drainage is equivalent to ERCP for primary treatment of malignant distal biliary obstruction: a systematic review and meta-analysis

Background and study aims  Although endoscopic retrograde cholangiopancreatography (ERCP) is standard of care for malignant biliary obstruction, endoscopic ultrasound-guided biliary drainage (EUS-BD) as a primary treatment has become increasingly utilized. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness and safety of EUS-BD for primary treatment of malignant biliary obstruction and comparison to traditional ERCP. Methods  Individualized search strategies were developed through November 2018 using PRISMA and MOOSE guidelines. A cumulative meta-analysis was performed by calculating pooled proportions. Subgroup analysis was performed for studies comparing EUS-BD versus ERCP. Heterogeneity was assessed with Cochran Q test or I ² statistics, and publication bias by funnel plot and Egger's tests. Results  Seven studies (n = 193 patients; 57.5 % males) evaluating primary EUS-BD for malignant biliary obstruction were included. Mean age was 67.4 years (2.3) followed an average of 5.4 months (1.0). For primary EUS-BD, pooled technical success, clinical success, and adverse event (AE) rates were 95 % (95 % CI 91 - 98), 97 % (95 % CI 93 - 100), and 19 % (95 % CI 11 - 29), respectively. Among EUS-BD and ERCP comparator studies, technical and clinical success, and total AEs were not different with lower rates of post-ERCP pancreatitis and reintervention among the EUS-BD group. Conclusion  Primary EUS-BD is an effective treatment with few AE. Comparing EUS-BD versus ERCP, EUS-BD has comparable efficacy and improved safety as a primary treatment for malignant biliary obstruction. Further randomized trials should be performed to identify patient populations and clinical scenarios in which primary EUS-BD would be most appropriate.

Primary Sclerosing Cholangitis: A Clinical Update

Primary sclerosing cholangitis (PSC) is a rare cholestatic disorder of the liver, with strictures in the bile ducts leading to cirrhosis of the liver in a proportion of patients. PSC is commonly associated with inflammatory bowel disease and increased risk of cholangiocarcinoma, gall bladder cancer, colorectal cancer, and hepatocellular carcinoma. Medical therapies are primarily aimed at symptom management and disease-modifying therapies are limited. Endoscopic therapies are used in patients with dominant strictures and liver transplantation is a last resort. In this article, the authors aim to comprehensively review the epidemiology, diagnosis, and management of PSC with emphasis on risk of malignancies and management of PSC. The authors also survey the advances in pathogenesis understanding and novel medical therapies for PSC.

Hepatic artery pseudoaneurysm following percutaneous transhepatic cholangiogram: an extremely rare complication

A 72-year-old female patient who was admitted for ischaemic stroke had developed ascending cholangitis. Percutaneous transhepatic cholangiogram was performed to drain the infected bile, but this was complicated by haemorrhagic shock and hepatic haematoma. Mesenteric angiogram showed right hepatic artery (RHA) pseudoaneurysm which was embolised, there by stopping her bleeding. RHA is normally located posterior to common bile duct (CBD). An uncommon location of RHA is anterior to CBD, which can lead to haemorrhagic complications during percutaneous cholangiogram.

Preventative care in cholestatic liver disease: Pearls for the specialist and subspecialist

Cholestatic liver diseases (CLDs) encompass a variety of disorders of abnormal bile formation and/or flow. CLDs often lead to progressive hepatic insult and injury and following the development of cirrhosis and associated complications. Many such complications are clinically silent until they manifest with severe sequelae, including but not limited to life-altering symptoms, metabolic disturbances, cirrhosis, and hepatobiliary diseases as well as other malignancies. Primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) are the most common CLDs, and both relate to mutual as well as unique complications. This review provides an overview of PSC and PBC, with a focus on preventive measures aimed to reduce the incidence and severity of disease-related complications.

Stent placement by EUS or ERCP for primary biliary decompression in pancreatic cancer: a randomized trial (with videos)

BACKGROUND AND AIMS

Studies on EUS-guided transmural biliary drainage (EUS-BD) have evaluated its efficacy as a rescue technique after failed ERCP. We performed a single-center, single-blind, randomized trial to compare EUS-BD and ERCP as primary treatment for distal biliary obstruction in pancreatic cancer.

METHODS

Patients underwent EUS-BD (n = 33) or ERCP (n = 34). The primary endpoint was the rate of adverse events. Secondary endpoints were technical success, treatment success (defined as decline in serum bilirubin by 50% at a 2-week follow-up), reinterventions, and intraoperative technical outcome, when applicable. Follow-up was until death or a minimum of 6 months.

RESULTS

The rates of adverse events were 21.2% (6.1% moderate severity; others mild severity) in the EUS-BD group and 14.7% (5.9% moderate severity; others mild severity) in the ERCP group (risk ratio, .69; 95% confidence interval, .24-1.97; P = .49). There were no procedure-related deaths. There was no significant difference in the rates of technical success (90.9% vs 94.1%, P = .67), treatment success (97% vs 91.2%, P = .61), or reinterventions (3.0% vs 2.9%, P = .99) between EUS-BD and ERCP cohorts, respectively. The endoscopic interventions did not impede subsequent pancreaticoduodenectomy that was performed in 5 of 33 patients (15.2%) in the EUS-BD and 5 of 34 patients (14.7%) in the ERCP group (P = .99).

CONCLUSIONS

Given the similar rates of adverse events and treatment outcomes in this randomized trial, EUS-BD is a practical alternative to ERCP for primary biliary decompression in pancreatic cancer. (Clinical trial registration number: NCT03054987.).

Bleeding after Percutaneous Transhepatic Biliary Drainage: Incidence, Causes and Treatments

Of all procedures in interventional radiology, percutaneous transhepatic biliary drainage (PTBD) is amongst the most technically challenging. Successful placement requires a high level of assorted skills. While this procedure can be life-saving, it can also lead to significant iatrogenic harm, often manifesting as bleeding. Readers of this article will come to understand the pathophysiology and anatomy underlying post-PTBD bleeding, its incidence, its varied clinical manifestations and its initial management. Additionally, a structured approach to its treatment emphasizing endovascular and percutaneous methods is given.

Primary Sclerosing Cholangitis: What the Gastroenterologist and Hepatologist Needs to Know

Primary sclerosing cholangitis (PSC) is a chronic, idiopathic biliary tract disease characterized by segmental strictures. The disease is progressive with no proven treatments and may eventually lead to cirrhosis and end-stage liver disease. Abrupt changes in liver biochemistries, pain, and/or cholangitis may suggest a dominant stricture amenable to endoscopic therapy or the development of cholangiocarcinoma. Patients with PSC are at increased risk of cholangiocarcinoma. There is a strong association with inflammatory bowel disease, and an associated increased risk of colorectal cancer. Colonoscopy every 1 to 2 years is appropriate.

Late liver function test abnormalities post-adult liver transplantation: a review of the etiology, investigation, and management

Approximately 24,000 liver transplants are performed annually worldwide, almost 7000 of which are performed in the USA. Survival is excellent and continues to improve, with 1-year survival currently exceeding 85 %, but effective management of patients after liver transplantation is critical to achieve optimal results. A plethora of diseases can affect the transplanted allograft, ranging from recurrence of the original disease to de novo liver pathology, and diagnosis can be complicated by nonclassical presentation, de novo disease, or inconclusive histology. Patients can remain asymptomatic despite significant damage to the transplanted liver, so prompt identification and treatment of liver disease after transplantation is crucial to preserve allograft function. Liver function tests are routinely taken throughout the postoperative period to monitor the graft. Although nonspecific, they are inexpensive, noninvasive, and sensitive for allograft disease and can quickly alert physicians to the presence of asymptomatic pathology. This review will outline possible causes of liver function test abnormalities in the late posttransplant period and provide guidance for investigation, diagnosis, and management.

ACG Clinical Guideline: Primary Sclerosing Cholangitis

Primary sclerosing cholangitis is a chronic cholestatic liver disease that can shorten life and may require liver transplantation. The cause is unknown, although it is commonly associated with colitis. There is no approved or proven therapy, although ursodeoxycholic acid is used by many on an empiric basis. Complications including portal hypertension, fat-soluble vitamin deficiency, metabolic bone diseases, and development of cancers of the bile duct or colon can occur.

Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations

Acute upper gastrointestinal (GI) bleeding remains one of the most common encounters in emergency medicine. The increased use of non-steroid anti-inflammatory drugs by the general population and the increased prescription of anti-platelet agents and anti-coagulants after cardiovascular interventions and for prevention of cerebral vascular accidents may have aggravated the situation. Significant progress has been made in the past decade or so in the non-surgical management of acute upper GI bleeding emergencies. This article will review the current standard treatment of the most common upper GI bleeding emergencies in adults as supported by evidence-based medicine with practical considerations from the authors' own practice experience.

Direct puncture embolization using N-butyl cyanoacrylate for a hepatic artery pseudoaneurysm

Massive hemobilia caused by hepatic artery pseudoaneurysm is an uncommon but potentially fatal complication that can occur after biliary intervention. Previous intervention or surgery, atherosclerotic disease, inflammation and even anatomic variants may make the pseudoaneurysm inaccessible to transcatheter approach, therefore it is not always feasible. The present report describes a case of successful embolization of a hepatic artery pseudoaneurysm with N-butyl cyanoacrylate via direct puncture as an alternative approach. The case presentation is followed by the technical points and the properties of N-butyl cyanoacrylate that are particularly advantageous for use in direct puncture procedures.

Interventional radiology and the pancreatic cancer patient

Patients with pancreatic cancer have a dismal prognosis. This article reviews the role that interventional radiology can play in managing postoperative complications and in patient palliation, particularly with an obstructed biliary system. In addition, options for cytoreduction are discussed, including chemoembolization, radioembolization, and thermal ablation. The final option reviewed is irreversible electroporation, which is being explored as a technique to allow patients with locally advanced pancreatic cancer to be converted to surgical candidates.

A case of successful placement of a fully covered metallic stent for hemobilia secondary to hepatocellular carcinoma with bile duct invasion

Hemobilia represents gastrointestinal bleeding that develops as a result of communication between blood vessels and the biliary tract, which causes the blood to reach the duodenal papilla. It is characterized by biliary colic as the initial symptom, and the complications of cholangitis, obstructive jaundice and/or anemia. In general, definitive diagnosis is made by esophagogastroduodenoscopy which confirms bleeding from the duodenal papilla. Abdominal US and abdominal enhanced CT are performed to identify the source of the bleeding, as well as ERCP for biliary drainage to control the comorbid cholangitis. If active hemorrhage accompanied by worsening of the anemia is suspected, abdominal angiography is performed to selectively image the hepatic artery. Then, embolization of the culprit vessel is recommended. In our patients with difficult hemostasis, because of the direct compression hemostasis to the tumor site achieved with the fully covered metallic stent and secondary compression hemostasis due to blood clots, the bleeding could be controlled.

Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of the literature

OBJECTIVE

Hemobilia is an uncommon cause of gastrointestinal bleeding. The etiology is diverse, but most often, it is iatrogenic. The present study aims to reassess the clinical picture and the treatment of choice.

METHODS

We describe a case series from a single center of patients who presented with nontraumatic iatrogenic hemobilia.

RESULTS

Over a period of 8 years, hemobilia occurred in 12 patients: following liver biopsy in six patients and after endoscopic biliary interventions in four patients, with a respective prevalence of 0.1 and 0.04%. The clinical presentation was characterized by an upper gastrointestinal bleeding (n=11) and/or biochemical signs of sudden biliary obstruction (n=9). The onset of the symptoms occurred after a median of 6 days (range: 1-23). Ultrasound and computed tomography scan missed the diagnosis in, respectively, 4/5 and 2/5 of patients. On arteriography, pseudoaneurysm (6/12) was the most common finding. Transcatheter arterial embolization controlled the bleeding in all cases (12/12) without major complications.

CONCLUSION

The delay between the intervention and the clinical presentation and the fact that imaging studies may fail to diagnose hemobilia may mislead the physician. Transcatheter arterial embolization is the treatment of choice for hemobilia. It has proven to be effective and safe and it offers a long-term definitive cure.

The role of ultrasound and magnetic resonance cholangiopancreatography for the diagnosis of biliary stricture after liver transplantation

PURPOSE

To identify the diagnostic value of ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing biliary strictures after liver transplantation.

MATERIALS AND METHODS

Sixty patients with clinically suspected biliary strictures after liver transplantation were retrospectively evaluated. All patients underwent US and MRCP before the standard of reference (SOR) procedure: endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Radiological images were analyzed for biliary dilatation and strictures.

RESULTS

By SOR, biliary dilatation was present in 55 patients, stricture in 53 (44 anastomotic, 4 intrahepatic, 5 both), and dilatation and/or stricture in 58. Dilatation was diagnosed by US and MRCP in 39 and 45, respectively (sensitivity 71% vs. 82%, p=0.18). Stricture was diagnosed by US and MRCP in 0 and 42, respectively (sensitivity 0% vs. 79%, p<0.0001). False positive stricture was diagnosed by MRCP in 2. Dilatation and/or stricture was diagnosed by US in 39 and MRCP in 50 (sensitivity 67% vs. 86%, p=0.01); however, using both techniques, sensitivity increased to 95%.

CONCLUSIONS

MRCP is superior to US for diagnosing biliary strictures after liver transplantation primarily because MRCP can detect stricture. The combination of US and MRCP seems superior to either method alone. Our data suggest that in patients with normal US and MRCP, direct cholangiography could be avoided.

Hepatic arterial injuries in 3110 patients following percutaneous transhepatic biliary drainage

PURPOSE

To evaluate the frequency of hepatic arterial injury in 3110 patients who had undergone percutaneous transhepatic biliary drainage (PTBD) and assess the risk factors for hepatic arterial injury and the treatment outcome after transcatheter arterial embolization.

MATERIALS AND METHODS

A total of 3110 patients who underwent 3780 PTBDs between January 2003 and December 2008 were retrospectively assessed. This study was approved by the Institutional Review Board. The incidence of hepatic arterial injury was determined and the risk factors associated with it were analyzed by using univariate and multiple logistic regression analyses. Hepatic angiography was performed to identify the bleeding focus, followed by transcatheter arterial embolization.

RESULTS

Hepatic arterial injuries occurred after 72 (1.9%) of 3780 PTBDs. When adjusted for benign disease, perihepatic ascites, platelet count of 50,000/mm(3) or less, international normalization ratio of 1.5 or greater, and left-sided puncture, multiple logistic regression analysis showed that left-sided PTBD (odds ratio, 2.017; 95% confidence interval: 1.257, 3.236; P = .004) was the only independent risk factor associated with hepatic arterial injury. The technical and clinical success rates of transcatheter arterial embolization were 100% and 95.8%, respectively. Minor complications were observed in 58 (80.6%) patients, 55 (76.4%) of whom had hepatic ischemia and three (4.2%) of whom had focal hepatic infarction. No major complication was observed in any patient.

CONCLUSION

Hepatic arterial injury is a relatively rare complication of PTBD. Because left-sided PTBD is the only independent risk factor associated with hepatic arterial injury, right-sided PTBD is preferable unless technical difficulty or secondary intervention necessitates left-sided PTBD. Moreover, transcatheter arterial embolization is a safe and effective method for treating hepatic arterial injury following PTBD.

Complications of endoscopic and radiologic investigation of biliary tract disorders

The investigation and treatment of disorders of the human biliary tree depend considerably on invasive endoscopic and radiologic procedures. These are associated with a significant risk of complications, some of which can be fatal. This review looks at these complications through the lens of 40 years of publications in the medical literature, and identifies the strengths and weaknesses of their current classification, diagnosis, and treatment.

Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review

AIM

To assess the published evidence on the endovascular treatment of non-variceal upper gastrointestinal haemorrhage.

MATERIALS AND METHODS

An Ovid Medline search of published literature was performed (1966-2009). Non-English literature, experimental studies, variceal haemorrhage and case series with fewer than five patients were excluded. The search yielded 1888 abstracts. Thirty-five articles were selected for final analysis.

RESULTS

The total number of pooled patients was 927. The technical and clinical success of embolization ranged from 52-100% and 44-100%, respectively. The pooled mean technical/clinical success rate in primary upper gastrointestinal tract haemorrhage (PUGITH) only, trans-papillary haemorrhage (TPH) only, and mixed studies were 84%/67%, 93%/89%, and 93%/64%, respectively. Clinical outcome was adversely affected by multi-organ failure, shock, corticosteroids, transfusion, and coagulopathy. The anatomical source of haemorrhage and procedural variables did not affect the outcome. A successful embolization improved survival by 13.3 times. Retrospective comparison with surgery demonstrated equivalent mortality and clinical success, despite embolization being applied to a more elderly population with a higher prevalence of co-morbidities.

CONCLUSIONS

Embolization is effective in this very difficult cohort of patients with outcomes similar to surgery.

[Hemobilia as the initial manifestation of cholangiocarcinoma in a patient with choledochoduodenostomy]

Hemobilia occurs when injury or disease causes communication between intrahepatic blood vessels and the intrahepatic or extrahepatic biliary system. The causes of hemobilia include trauma, gallstone disease, vascular malformation, inflammation, and biliary or hepatic tumors. Hemobilia could be diagnosed by endoscopy, hepatic angiography, computed tomography, and ultrasonogram. Patients with hemobilia may present with biliary colic, obstructive jaundice and gastrointestinal bleeding. Extrahepatic cholangiocarcinoma usually presents with obstructive jaundice and is one of the unusual cause of hemobilia. We, herein, report a case of hemobilia caused by cholangiocarcinoma in a 69-year-old woman. She had the past history of lung cancer and choledochoduodenostomy due to gallstone. Esophagogastroduodenoscopy revealed a blood clot protruding from the choledochoduodenostomy site and the ulcerative mass in the common bile duct. Pathologic examination of the ulcerative mass was compatible with those of cholangiocarcinoma.

Transcatheter embolization for peripheral pseudoaneurysms with n-butyl cyanoacrylate

The purpose of this study is to evaluate the clinical efficacy of transcatheter embolization for pseudoaneurysms of peripheral arteries with n-butyl cyanoacrylate (NBCA). From November 2000 to February 2008, 17 patients with 18 pseudoaneurysms were treated by transcatheter embolization at our affiliated hospitals. The locations of the pseudoaneurysms were right hepatic artery (n=3), renal artery (n=5), splenic artery (n=2), gastroduodenal artery (n=2), common hepatic artery (n=1), pancreatic arcade (n=1), external iliac artery (n=1), internal iliac artery (n=1), internal thoracic artery (n=1), and left gastric artery (n=1). We assessed technical success rate, embolization methods, and clinical course in this study. The technical success rate was 94.4% (17/18 cases). Embolization methods were isolation (n=17) and packing (n=1). Only NBCA was used in 14 cases, both coils and NBCA were used in four cases. Six patients were in shock prior to the procedure, but all patients recovered immediately after embolization procedure including transfusion. None of the patients died of procedure-related factors or had notable postoperative complications, but three patients died within a week of the procedure because of deterioration of the underlying disease. In conclusion, transcatheter embolization of pseudoaneurysms with NBCA is a safe and effective technique for treatment.

Hilar cholangiocarcinoma: current management

OBJECTIVE

To review the literature with regard to outcome of surgical management for hilar cholangiocarcinoma (Klatskin tumor).

BACKGROUND

Hilar cholangiocarcinoma is a rare tumor with a poor prognosis. Surgical resection provides the only possibility for cure. Advances in hepatobiliary imaging and surgical strategies to treat this disease have resulted in improved postoperative outcomes.

METHODS

We performed a review of the English literature on hilar cholangiocarcinoma from 1990 to 2007. This review included preoperative evaluation, surgical techniques, issues and controversies in management, prognostic variables, and considerations for future directions.

RESULTS

Complete resection remains the most effective and only potentially curative therapy for hilar cholangiocarcinoma. Negative resection margins are associated with improved outcomes, and major hepatic resections have enhanced the likelihood of R0 resection. Portal vein embolization may be indicated in selected patients before extensive hepatic resection. Staging laparoscopy should be considered to detect occult metastatic disease. Orthotopic liver transplantation might be applicable for a highly selected subgroup.

CONCLUSIONS

Surgical resection including major hepatic resection remains the mainstay of treatment of hilar cholangiocarcinoma. Additional evidence is needed to fully define the role of orthotopic liver transplantation. Improvements in adjuvant therapy are essential for improving long-term outcome.

Intra-hepatic arterial pseudoaneurysm causing life-threatening upper gastrointestinal bleed after removal of biliary drainage catheter

Hepatic artery pseudoaneurysms are an uncommon complication of percutaneous biliary drainage catheter insertion. The authors report a case of a hepatic artery pseudoaneurysm following percutaneous internal-external biliary drain insertion. This led to massive haemobilia when the catheter was removed and presented clinically as life-threatening upper gastrointestinal bleed. The clinical and imaging manifestations are discussed along with the management of the patient.

Vascular complications associated with percutaneous biliary drainage: a report of three cases

Percutaneous biliary drainage is a common interventional radiology procedure. It is usually performed in the setting of biliary obstruction, benign or malignant, after endoscopic approach failed or is technically not possible. Percutaneous biliary drainage has a relatively low complication rate, and most complications that occur are usually self-limited. Major complications, however, can occur. In this article, we report three major hemorrhagic complications and their management. They include hemorrhage secondary to fistula formation and pseudoaneurysm formation occurring several days to weeks subsequent to the initial drain placement.

Pseudoaneurysms of Hepatic Artery Branches: Treatment with Self-expanding Stent-grafts in Two Cases

Pseudoaneurysms of the hepatic artery or its branches are rare complications with several potential causes. Herein, the authors report two cases of pseudoaneurysms of hepatic artery branches, one secondary to laparoscopic surgery and the other probably due to malignancy. The pseudoaneurysms were treated with the placement of self-expanding stent-grafts. Complete and prompt occlusion of the pseudoaneurysm was achieved in both patients, with resolution of symptoms and preservation of the blood flow in the parent arterial branch at long-term follow-up.

Percutaneous embolization of transhepatic tracks for biliary intervention

Significant pain can occur after removing transhepatic catheters from biliary access tracks, after percutaneous biliary drainage (PBD) or stenting. We undertook a randomized prospective study to ascertain whether track embolization decreases the amount of pain or analgesic requirement after PBD. Fifty consecutive patients (M:F, 22:28; age range: 29-85 years; mean age: 66.3 years) undergoing PBD were randomized to receive track embolization or no track embolization after removal of biliary drainage catheters. A combination of Lipoidol and n-butyl cyanoacrylate were used to embolize transhepatic tracks using an 8F dilator. The patients who did not have track embolization performed had biliary drainage catheters removed over a guide wire. A visual analog scoring (VAS) system was used to grade pain associated with catheter removal, 24 h afterward. A required analgesic score (RAS) was devised to tabulate the analgesia required. No analgesia had a score of 0, oral or rectal nonopiate analgesics had a score of 1, oral opiates had a score of 2, and parenteral opiates had a score of 3. The average VAS and RAS for both groups were calculated and compared. Seven patients were excluded for various reasons, leaving 43 patients in the study group. Twenty-one patients comprised the embolization group and 22 patients comprised the nonembolization group. The mean biliary catheter dwell time was not significantly different (p > 0.05) between the embolization group and nonembolization (mean: 5.4 days vs 6.9 days, respectively). In the nonembolization group, the mean VAS was 3.4. Eight patients required parenteral opiates, three patients required oral opiates, and five patients required oral or rectal analgesics, yielding a mean RAS of 1.6. In the embolization group, the mean VAS was 0.9. No patient required parenteral opiates, six patients required oral opiates, and two patients had oral analgesia. The average RAS was 0.6. Both the VAS and the RAS were significantly lower in the embolization group compared with the nonembolization group (p < 0.0023 and p < 0.002, respectively). No complications were seen related to track embolization. Percutaneous track embolization after removal of biliary drainage catheters decreases patient's perception of pain and decreases the amount of required analgesia. In particular, the amount of opiate analgesia required is considerably less.

Utility of Stent-Grafts in Treatment of Porto-Biliary Fistula

A porto-biliary fistula causing hemobilia is a known complication of percutaneous transhepatic biliary drainage (PTBD). We present two patients with hemobilia secondary to porto-biliary fistula, treated successfully by percutaneous placement of stent-grafts. In one case, the stent-graft was placed in the bile duct, and in the other case, it was placed in the intrahepatic portal vein branch. Hemobilia stopped and there were no complications except a small area of hepatic infarction, distal to the stent-graft in the portal vein.

Intercostal artery pseudoaneurysm due to stab wound

Intercostal artery pseudoaneurysm is extremely rare, and only six cases have been reported in the English literature. We describe a case of intercostal artery pseudoaneurysm due to a stab wound, review the literature, and discuss therapeutic modalities. Intercostal artery pseudoaneurysm is at risk for early rupture, and diagnosis before rupture is mandatory. Although embolization is considered to be a feasible therapeutic method, we would emphasize the significance of the anatomic features of the intercostal arteries: multiple blood supplies into the pseudoaneurysm, such as the anterior and posterior intercostal arteries, and musculophrenic artery.

Nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization

We present our experience in the nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization. We treated 6 pseudoaneurysms (5 intrahepatic and 1 of the gastroduodenal artery), 6 vessel lacerations (1 common hepatic artery, 1 right hepatic artery, 1 gastroduodenal artery, 2 pancreatoduodenal, 1 polar intrasplenic artery), 1 arterioportal fistula, and 1 arteriobiliary fistula; all the bleeding lesions were secondary to surgical, endoscopic, or interventional radiologic procedures.

N-butyl cyanoacrylate embolization for control of acute arterial hemorrhage

PURPOSE

To report the initial clinical experience with the use of n-butyl cyanoacrylate (NBCA) for embolization of acute arterial hemorrhage from varied etiologies and at varied anatomic sites.

MATERIALS AND METHODS

Sixteen patients who demonstrated active extravasation of contrast material and/or arterial abnormality underwent NBCA embolization. Sites of embolization included the gastrointestinal tract, kidney, liver, uterus, adrenal gland, extremity, and chest wall. Standard coil or particulate embolization had previously failed in 10 patients. NBCA was used as the initial embolic agent in the remaining six patients. After treatment, serial hematocrit levels, transfusion requirements, and clinical signs and symptoms were monitored for stabilization. Patients were evaluated for signs and symptoms of end-organ damage.

RESULTS

NBCA embolization was successful in 12 of 16 patients (75%), who exhibited complete cessation of bleeding. In four patients (25%), NBCA embolization was of no benefit. Embolization failed in two of 16 patients (12.5%), who showed evidence of recurrent bleeding after use of NBCA. The remaining two patients (12.5%) died within 24 hours of the procedure. None of the 16 patients developed clinical signs of end-organ damage or iatrogenic ischemia attributable to NBCA.

CONCLUSIONS

In this initial limited series, NBCA embolization was shown to be a feasible and effective method to control acute arterial hemorrhage. NBCA embolization was able to stop arterial bleeding even when previous coil or particulate embolization had failed.

Iatrogenic hepatic artery pseudoaneurysms: an uncommon complication after hepatic, biliary, and pancreatic procedures

Hepatic artery pseudoaneurysms are uncommon but potentially lethal complications of hepatic, biliary, and pancreatic interventions. To enhance our knowledge about these pseudoaneurysms, we reviewed our institution's experience with the management of these lesions. We reviewed the literature on 136 cases of hepatic artery pseudoaneurysms as well as our experience with 17 patients (excluding patients who were post-transplantation or had suffered abdominal trauma). The causes, pathogenesis, and clinical features were analyzed. Ten women and seven men developed hepatic artery pseudoaneurysms after undergoing hepatic (65%), biliary (30%), or pancreatic procedures (5%). The mean time between initial intervention and diagnosis was 5.7 months (range 7 days-38 months). Rupture occurred in 13 patients (76%). Mean pseudoaneurysm size was 1.9 cm (range 0.7-4 cm). Embolization was successful in 12 of 14 patients (86%). Four patients (24%), including the two who failed embolization, required operative intervention. Postoperative mortality was 25% while postembolization mortality was 14%. One patient was observed, and the aneurysm thrombosed at 72 months follow-up. Mean follow-up was 48 months (range 1-184 months) for 13 of the 14 survivors (93%) (1 patient was lost to follow-up) without any clinical sequela. Hepatic artery pseudoaneurysms are rare. Rupture is common and occurred in 76% of patients. For both ruptured and nonruptured cases angiography with embolization of the pseudoaneurysm is safe and effective. Operative intervention should be reserved for patients for whom embolization fails or for whom it is not feasible.

Vascular complications in percutaneous transhepatic management of complicated hepatolithiasis with difficult intrahepatic biliary strictures: are they avoidable?

Little has been reported about hemobilia in the management of complicated residual or recurrent hepatolithiasis with intrahepatic biliary strictures by percutaneous stricture dilation and percutaneous transhepatic cholangioscopic lithotomy. To analyze retrospectively the incidence, possible factors, and management of hemobilia in such patients, a consecutive series of 177 patients was studied from 1983 to 2001: 90 patients in the early, 7.5-year period and 87 patients in the later period, in which some procedures were modified. Minor hemobilia occurred during percutaneous puncture in 6 patients: 4 (4.4%) in the early period and 2 (2.3%) in the later period. Massive hemobilia developed in 14 patients (15.5%) in only the early period, during stricture dilation, lithotripsy, or lithotomy. Immediate arteriography revealed arterial bleeding (7), extravasation (3), pseudoaneurysm (3), or an undetermined source (1). Transcatheter arterial intervention enabled successful hemostasis. Massive hemobilia is a potential serious complication of percutaneous stricture dilation and percutaneous transhepatic cholangioscopic lithotomy but is avoidable.

Measurement of needle-tip bioimpedance to facilitate percutaneous access of the urinary and biliary systems: first assessment of an experimental system

RATIONALE AND OBJECTIVES

Percutaneous access to the renal collecting system or biliary system is most frequently performed under image guidance. However, current techniques lack a feedback mechanism to help confirm successful access. A percutaneous needle system has been developed consisting of a modified 18-gauge percutaneous access needle that measures tissue impedance at its needle tip. Initial results in utilizing this novel system to determine successful access into dilated kidney and gall bladder specimens are reported.

METHODS

Impedance measurements were recorded as the needle was precisely advanced through ex vivo kidney and liver/gall bladder specimens. In an anesthetized porcine model, impedance values were recorded with laparoscopic visualization as the needle was advanced percutaneously through abdominal wall, liver, and into gall bladder.

RESULTS

A characteristic, reproducible drop in impedance was noted with successful entry into ex vivo distended kidney and gall bladder specimens. This feature was also noted during in vivo percutaneous cholecystostomy.

CONCLUSIONS

A measurable, characteristic drop in tissue impedance signifies successful entry into the urinary and biliary systems. This impedance needle system may facilitate current percutaneous access techniques.

[A case of hepatic pseudoaneurysm treated with percutaneous embolization in a child with multiple trauma]

Hepatic artery pseudoaneurysms are rare complications of blunt abdominal trauma in children. Diagnosis is frequently delayed and made by splanchnic angiography. Most of the indications for surgical treatment have disappeared after the development of selective catheterization and embolization. We report a case in an 8-year-old pedestrian who was struck by a car and suffered a multiple trauma with a severe blunt abdominal trauma. A severe collapse upon admission commanded immediate laparotomy that depicted a liver fracture with associated jejunal and pancreatic lesions. Recovery was progressive until the 15th postoperative day where an abrupt haemobilia occurred. A CT-scan exploration was performed and revealed a vascular mass lesion in the left lobe of the liver. The performance of a selective angiography confirmed the diagnosis of left artery pseudoaneurysm, but because of technical difficulties, no embolization could be performed by this way. A direct percutaneous puncture and embolization of the aneurysm allowed a complete exclusion of the lesion. Eventually, recovery was complete. This percutaneous technique could be a valuable alternative to classical embolization and could avoid surgical treatment that still carries a high morbidity.

Transcatheter arterial embolization of ruptured pseudoaneurysms with coils and n-butyl cyanoacrylate

PURPOSE

To evaluate the clinical efficacy of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA) for ruptured pseudoaneurysms, which are difficult to control by coil embolization alone.

MATERIALS AND METHODS

Ruptured pseudoaneurysms developed at the celiac trunk (n = 1), gastroduodenal artery (n = 2), pancreatic arcade (n = 1), hepatic artery (n = 3), renal artery (n = 1), and intercostal artery (n = 1) in nine patients. NBCA was mixed with iodized-oil (1:2) and injected via the 3-F microcatheter under fluoroscopic guidance, after the catheter was advanced close to the pseudoaneurysm. Coil embolization was performed to control blood flow before administration of NBCA in seven patients. NBCA was injected immediately after coil embolization in four patients. Embolization with NBCA was performed for recurrent bleeding that occurred within 1-21 days (mean, 10.7 days) after initial coil embolization in three patients. Two patients with peripheral pseudoaneurysms underwent embolization with NBCA alone.

RESULTS

The NBCA mixture was visible under fluoroscopy, and was useful in monitoring the embolization process and deciding the endpoint. Embolization was technically successful without major complications in all patients. Pseudoaneurysms and afferent and efferent arteries were eliminated immediately after embolization. Bleeding was stopped after embolization in all cases. Rebleeding did not occur in any patient during their follow-up periods of 0.7-69.5 months (mean, 17.9 months).

CONCLUSION

Embolization with NBCA is a feasible and useful treatment for ruptured pseudoaneurysms, which are difficult to control by coil embolization alone.

Active intrahepatic gadolinium extravasation following TIPS

A 31-year-old male patient had a transjugular intrahepatic portal systemic shunt (TIPS) placed for acute Budd-Chiari syndrome secondary to paroxysmal nocturnal hemoglobinuria (PNH). Post-procedure, he was anticoagulated for his underlying paroxysmal nocturnal hemoglobinuria. After 11 days, he complained of upper abdominal pain and underwent magnetic resonance imaging (MRI). On immediate post-gadolinium spoiled-gradient-echo (SGE) images, active extravasation of gadolinium was depicted in one of two intrahepatic hematomas. Progression of layering of high signal gadolinium was shown from early to later phase post-gadolinium images. The active arterial bleeding was confirmed by conventional angiography performed immediately following the magnetic resonance imaging.