Management of iatrogenic bile duct injuries: role of the interventional radiologist

Post-operative complications of cholecystectomy: what the radiologist needs to know

Cholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively.

An exploration of radiological signs in post-intervention liver complications

The advent and progression of radiological techniques in the past few decades have revolutionized the diagnostic and therapeutic landscape for liver diseases. These minimally invasive interventions, ranging from biopsies to complex therapeutic procedures like transjugular intrahepatic portosystemic shunt placement and transarterial embolization, offer substantial benefits for the treatment of patients with liver diseases. They provide accurate tissue diagnosis, allow real-time visualization, and render targeted treatment for hepatic lesions with enhanced precision. Despite their advantages, these procedures are not without risks, with the potential for complications that can significantly impact patient outcomes. It is imperative for radiologists to recognize the signs of these complications promptly to mitigate further health deterioration. Ultrasound, CT, and MRI are widely utilized examinations for monitoring the complications. This article presents an overarching review of the most commonly encountered hepatobiliary complications post-radiological interventions, emphasizing their imaging characteristics to improve patient post-procedure management.

Cholecystocutaneous fistula after cholecystectomy

Cholecystocutaneous fistula is an exceedingly rare type of external biliary fistula, where an abnormal connection forms between the gallbladder and the skin. Cholecystocutaneous fistula commonly develops in the setting of chronic calculus cholecystitis or following a previous surgical intervention involving the biliary tract. Patients with cholecystocutaneous fistula often present with systemic symptoms, such as fever, nausea, and vomiting, as well as localized symptoms in the right upper quadrant of the abdomen, where the external opening of the fistula is typically found. Ultrasonography, computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography (MRCP), and fistulograms (computed tomography or X-ray) are commonly used. Computed tomography has proven to be more effective than ultrasonography in delineating the fistulous tract and the associated fluid collections. Open cholecystectomy with excision of the fistulous tract is considered the gold standard and is curative in the majority of cases. However, a laparoscopic approach has become a viable alternative, especially in the hands of experienced surgeons.

The role of CEUS in the management of biloma

BACKGROUND

A biloma refers to an abnormal, well-defined accumulation of bile outside the biliary tree within the abdomen, which can be either intra- or extra-hepatic in nature. It can result from traumatic or iatrogenic causes, leading to a disruption in the biliary system. Without prompt diagnosis and appropriate management, it can result in significant morbidity and mortality. While magnetic resonance cholangiopancreatography (MRCP) is the typical diagnostic method, there are instances where it may not provide conclusive results.

CASE PRESENTATION

We present the case of a 72-year-old woman who underwent an hepatic resection of the seventh segment after recurrence of hepatocellular carcinoma (HCC). During the ultrasound (US) follow-up, she developed a peri-hepatic collection which proved to be a biloma continuously refurnished by the biliary tree. Neither the MRCP nor the percutaneous transhepatic cholangiography (PTC) were able to clearly detect the exact site of the bile leak. While awaiting the Endoscopic Retrograde Cholangio-Pancreatography (ERCP), a Contrast-Enhanced Ultrasound (CEUS) was conducted administering the contrast agent directly through the percutaneous drainage catheter placed in the biloma. This revealed the presence of contrast flow from the collection to a peripheral right bile duct, confirming the intra-hepatic leak communication.

CONCLUSIONS

This case demonstrates that Contrast-Enhanced Ultrasound (CEUS) presents a straightforward, secure, and precise approach to detect biliary leakage responsible for the formation of a biloma. Additionally, the adoption of CEUS offers the dual benefit of minimizing radiation exposure for the patient and obviating the requirement for anesthesia. In summary, CEUS emerges as a compelling alternative to conventional diagnostic methods for effectively managing a biloma.

Biliary Leaks: Multidisciplinary Approach to Diagnosis and Treatment

Bile leaks arise from various causes such as trauma, complications after hepatobiliary surgery, and intrahepatic malignancies or their associated liver-directed treatments. Bile leaks can result in significant morbidity and mortality. Delayed diagnosis is not uncommon due to nonspecific manifestations; therefore, a high clinical suspicion is needed. A multidisciplinary approach for treatment of biliary leaks with prompt referral to tertiary care centers with experienced hepatobiliary surgeons, advanced endoscopists, and interventional radiologists is needed to address these challenging complications. Management of biliary leaks can range from conservative management to open surgical repair. Minimally invasive procedures play a crucial role in biliary leak treatment, and the interventional radiologist can help guide appropriate management on the basis of a clear understanding of the pathophysiology of biliary leaks and a current knowledge of the armamentarium of treatment options. In most cases, a simple diversion of bile to decompress the biliary system may prove effective. However, persistent and high-output biliary leaks require delineation of the source with tailored treatment options to control the leak. This may be done by additional diversions, occluding the source, reestablishing connections, or using a combination of therapies to bridge to more definitive surgical interventions. The authors describe the different treatment options and emphasize the role of interventional radiology. ©RSNA, 2024.

Percutaneous transhepatic bilioenteric neoanastomosis: A novel approach for managing bile duct injuries following choledochal cyst resection in patients with anatomical variations of the biliary tree: A case study

Bile duct injuries are rare complications of hepatobiliary pancreatic surgery, leading to severe complications if not timely diagnosed and treated, with surgery traditionally being the primary treatment option. However, percutaneous transhepatic or endoscopic interventions have recently gained widespread use. We present a case study of a patient with variant biliary anatomy, who suffered biliary tract injury postcholedochal cyst resection and Roux-en-Y hepaticojejunostomy; successfully treated with percutaneous transhepatic bilioenteric neoanastomosis, guided by ultrasound and digital subtraction angiography (DSA).

Endoscopic repair of surgically transected bile duct using overlapping covered metal stents

Video 1Endoscopic repair of surgically transected bile duct using overlapping covered metal stents.

Transarterial Bleomycin-Lipiodol Chemoembolization for the Treatment of Giant Hepatic Hemangiomas: An Assessment of Effectiveness

This study evaluates the effectiveness of superselective transcatheter arterial chemoembolization (TACE) using a bleomycin-lipiodol emulsion in treating giant hepatic hemangiomas. A retrospective review included 31 patients with a mean age of 53 ± 10.42 years who underwent TACE from December 2014 to October 2022, with follow-up imaging examinations to assess outcomes. Technical success was defined as successful embolization of all feeding arteries, and clinical success was defined as a reduction in hemangioma volume by 50% or more on follow-up imaging. This study observed a 100% technical success rate. Post-embolization syndrome was common, and two cases of asymptomatic hepatic artery dissection were noted. Clinical success was achieved in 80.6% of patients, with significant volume reduction observed in the majority. Conclusively, superselective transcatheter arterial chemoembolization with bleomycin-lipiodol emulsions is presented as a viable and effective treatment option for giant hepatic hemangiomas. With no procedure-related mortality and significant volume reduction in most cases, this method offers a promising alternative to surgical intervention. This study's findings suggest a need for further exploration and validation in larger-scale prospective studies.

Post-cholecystectomy iatrogenic bile duct injuries: Emerging role for endoscopic management

Post-cholecystectomy iatrogenic bile duct injuries (IBDIs), are not uncommon and although the frequency of IBDIs vary across the literature, the rates following the procedure of laparoscopic cholecystectomy are much higher than open cholecystectomy. These injuries caries a great burden on the patients, physicians and the health care systems and sometime are life-threatening. IBDIs are associated with different manifestations that are not limited to abdominal pain, bile leaks from the surgical drains, peritonitis with fever and sometimes jaundice. Such injuries if not witnessed during the surgery, can be diagnosed by combining clinical manifestations, biochemical tests and imaging techniques. Among such techniques abdominal US is usually the first choice while Magnetic Resonance Cholangio-Pancreatography seems the most appropriate. Surgical approach was the ideal approach for such cases, however the introduction of Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was a paradigm shift in the management of such injuries due to accepted success rates, lower cost and lower rates of associated morbidity and mortality. However, the literature lacks consensus for the optimal timing of ERCP intervention in the management of IBDIs. ERCP management of IBDIs can be tailored according to the nature of the underlying injury. For the subgroup of patients with complete bile duct ligation and lost ductal continuity, transfer to surgery is indicated without delay. Those patients will not benefit from endoscopy and hence should not do unnecessary ERCP. For low-flow leaks e.g. gallbladder bed leaks, conservative management for 1-2 wk prior to ERCP is advised, in contrary to high-flow leaks e.g. cystic duct leaks and stricture lesions in whom early ERCP is encouraged. Sphincterotomy plus stenting is the ideal management line for cases of IBDIs. Interventional radiologic techniques are promising options especially for cases of failed endoscopic repair and also for cases with altered anatomy. Future studies will solve many unsolved issues in the management of IBDIs.

Optimizing surgical management of iatrogenic bile duct injury: transhepatic percutaneous cholangial drainage combined with end-to-end biliary anastomosis

Iatrogenic bile duct injury remains the most severe complication of gallbladder surgeries. To reduce post-operation complication, we introduce an improved approach for bile duct injury repairment, named transhepatic percutaneous cholangial drainage (TPCD) which combined with end-to-end biliary anastomosis. Clinical data obtained from 12 patients between February 2012 and May 2022 were retrospectively analyzed. Patient demographic, clinical, operative, and follow-up data were analyzed using descriptive statistics. All injuries were repaired successfully and no fatal cases occurred. The mean operative time and hospital stay duration were 367.5 ± 103.2 min and 11.3 ± 3.5 days, respectively. In two cases (16.7%), bile leakage occurred at the bile duct anastomosis site. Three patients (25.0%) developed low-grade fever and one patient (8.3%) developed a postoperative infection of the incision site. No postoperative bleeding or bile duct strictures occurred in any of the cases. The patients were followed up from 12 to 122 months (median, 70.5 months). No cholangitis or bile duct restenosis was observed after biliary drainage tube removal. There were no long-term bile duct-related complications seen in the follow-up time. It is safe and feasible for TPCD combined with end-to-end biliary anastomosis using in bile duct injury.

Percutaneous transhepatic biliary drainage (PTBD) in patients with biliary leakage: Technical and clinical outcomes

The purpose of this study is to evaluate the technical and clinical outcome of percutaneous transhepatic biliary drainage (PTBD) in patients with biliary leakage. All patients who underwent ultrasound-assisted PTBD between January 2017 and December 2021 due to biliary leakage with nondilated biliary systems were retrospectively evaluated for periprocedural characteristics, medical indications, technical success (successful placement of drainage catheter), clinical success (resolved leak without additional procedures), fluoroscopy time, procedure duration, and clinical outcomes. 74 patients with a mean age of 64.1 ± 15.1 years were identified. Surgery was the most common etiology of biliary leak with 93.2% of the cases. PTBD had a 91.8% (68/74) technical success rate and an 80.8% clinical success rate. The mean procedure and fluoroscopy duration were 43.5 and 18.6 minutes. Age > 65 years (P = .027) and left-sided drainage (P = .034) were significant risk factors of clinical failure. Procedure-related major complications were 2 bleedings from the liver and 1 bleeding from an intercostal artery (major complication rate 4%). PTBD is a feasible, safe, and effective treatment option in patients with biliary leakage with low complication rates.

Significance of Postprocedural Contrast Medium Injection after CT-Guided Abscess Drainage

The aim was to evaluate the additive clinical value of an additional post-procedural control-scan after CT-guided percutaneous abscess drainage (PAD) placement with contrast medium (CM) via the newly placed drain. All CT-guided PADs during a 33-month period were retrospectively analyzed. We analyzed two subgroups, containing patients with and without surgery before intervention. Additionally, radiological records were reevaluated, concerning severe inflammatory response syndrome (SIRS) during the intervention. A total of 499 drainages were placed under CT-guidance in 352 patients. A total of 197 drainages were flushed with CM directly after the intervention, and 51 (26%) showed an additional significant finding. An immediate change of therapy was found in 19 cases (9%). The subgroup that underwent surgery (120 CM-drainages; 32 (27%) additional findings; 13 (11%) immediate changes of therapy) showed no statistically significant difference compared to the subgroup without surgery (77 CM-drainages; 19 (25%) additional findings; 5 (6%) immediate changes of therapy). SIRS occurred in 2 of the 197 flushed drainages (1%) after CM application. An additional scan with CM injection via the newly placed drain revealed clinically significant additional information in almost 26% of the drainages reviewed in this study. In 9% of the cases this information led to an immediate change of therapy. Risks for SIRS are low.

Hepaticojejunostomy for bile duct injury: state of the art

BACKGROUND

Hepaticojejunostomy (HJ) is the gold standard procedure for the reconstruction of the bile duct in many benign and malignant situations. One of the major situation is the bile duct injury (BDI) after cholecystectomy, either for early or late repair. This procedure presents some specificities associated to a debated management of BDI.

PURPOSE

This article provides a state-of-the-art of the hepaticojejunostomy procedure focusing on bile duct injury including its indications and outcomes CONCLUSION: Performed at the right moment and respecting the technical rules, HJ provides a restoration of the biliary patency in the long term of 80 to 90%. It is the main surgical technique to repair BDI. Complications and failure of this procedure can be difficult to manage. That is why the primary repair requires an appropriate multidisciplinary approach associated with an expert high quality surgical technique.

Imaging Features of Main Hepatic Resections: The Radiologist Challenging

Liver resection is still the most effective treatment of primary liver malignancies, including hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), and of metastatic disease, such as colorectal liver metastases. The type of liver resection (anatomic versus non anatomic resection) depends on different features, mainly on the type of malignancy (primary liver neoplasm versus metastatic lesion), size of tumor, its relation with blood and biliary vessels, and the volume of future liver remnant (FLT). Imaging plays a critical role in postoperative assessment, offering the possibility to recognize normal postoperative findings and potential complications. Ultrasonography (US) is the first-line diagnostic tool to use in post-surgical phase. However, computed tomography (CT), due to its comprehensive assessment, allows for a more accurate evaluation and more normal findings than the possible postoperative complications. Magnetic resonance imaging (MRI) with cholangiopancreatography (MRCP) and/or hepatospecific contrast agents remains the best tool for bile duct injuries diagnosis and for ischemic cholangitis evaluation. Consequently, radiologists should be familiar with the surgical approaches for a better comprehension of normal postoperative findings and of postoperative complications.

Multimodality Imaging of Cholecystectomy Complications

Cholecystectomy is one of the most common surgeries performed in the United States. Although complications are uncommon, the high incidence of this surgery means that a radiologist will likely encounter these complications in practice. Complications may arise in the immediate postoperative period or can be delayed for weeks, months, or years after surgery. Vague and nonspecific symptoms make clinical diagnosis challenging. As a result, multimodality imaging is important in postoperative evaluation. US and multidetector CT are the usual first-line imaging modalities. Hepatobiliary scintigraphy, SPECT/CT, and MRI with conventional or gadoxetate hepatobiliary contrast material are important and complementary modalities that are used for workup. The authors begin with a brief discussion of surgical technique and expected postoperative findings and then describe complications organized into four groups: (a) biliary complications, (b) stone-related complications, (c) iatrogenic complications, and (d) gallbladder complications. Biliary complications include bile leaks and bilomas, acute biliary obstruction, and biliary stricture. Stone-related complications include retained and recurrent stones and spillage of stones into the peritoneum. Iatrogenic complications include hemorrhage, vasculobiliary injury, arterial pseudoaneurysms, duodenal injury, and migration of clips. Gallbladder complications include recurrent cholecystitis after subtotal reconstituting cholecystectomy and unexpected gallbladder cancer. An invited commentary by Mullens and Ibrahim is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Early versus delayed reconstruction for bile duct injury a multicenter retrospective analysis of a hepatopancreaticobiliary group

Common bile duct injury is a severe complication. It is related to increased rates of morbidity and mortality. Early recognition and on-time diagnosis plus multidisciplinary management of this disease led by a hepatobiliary surgeon show fewer complications rate and best postoperative outcomes. However, no guidelines exist about the proper time of reconstruction. This study aims to describe the experience of a specialized Hepato-Pancreatic-Biliary (HPB) group and to analyze the outcomes regarding the time of bile duct injury (BDI) repair. A multicenter retrospective review of a prospective database was conducted. All the patients older than 18 years old that underwent common bile duct reconstruction between January 2014 and December 2021 were included. Analysis and description of preoperative characteristics and postoperative outcomes were performed. A reconstruction time-based group differentiation was made and analyzed. 44 patients underwent common bile duct reconstruction between January 2014 and December 2021. 56.82% of the patients were female. The mean age was 53.27 years ± 20.7 years. The most common injury was type E2 (29.55%). Hepaticojejunostomy was performed in 81.81% (of the patients. Delayed reconstruction (> 72 h) was performed in the majority of the cases (75.00%) due to delays in the referral centers or poor condition. No statistically significant difference regarding complications in early or delayed BDI reconstruction. The mortality rate was 2.7% (n = 1). 2-year follow-up bilioenteric stenosis was observed in 7 patients. Biloma showed a statistical relationship with complex bile duct injuries (p = 0.02). Bile duct injury is a severe and complex postoperative complication that increases morbidity and mortality rates in the short and long term in patients undergoing cholecystectomy. In our study, there were no statistical differences between the timing of bile duct reconstruction and the postoperative outcomes; we identified the presence of biloma as a statistically related factor associated with complex bile duct injury; however, further prospective or studies with an increased sample size are required to prove our results.

Imaging Features of Main Posthepatectomy Complications: A Radiologist’s Challenge

In the recent years, the number of liver resections has seen an impressive growth. Usually, hepatic resections remain the treatment of various liver diseases, such as malignant tumors, benign tumors, hydatid disease, and abscesses. Despite technical advancements and tremendous experience in the field of liver resection of specialized centers, there are moderately high rates of postoperative morbidity and mortality, especially in high-risk and older patient populations. Although ultrasonography is usually the first-line imaging examination for postoperative complications, Computed Tomography (CT) is the imaging tool of choice in emergency settings due to its capability to assess the whole body in a few seconds and detect all possible complications. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for delineating early postoperative bile duct injuries and ischemic cholangitis that may arise in the late postoperative phase. Moreover, both MDCT and MRCP can precisely detect tumor recurrence. Consequently, radiologists should have knowledge of these surgical procedures for better comprehension of postoperative changes and recognition of the radiological features of various postoperative complications.

The Utility of Biliary Manometry in Assessing Early Catheter Removal After Percutaneous Balloon Dilatation of Hepaticojejunostomy Strictures

Background and objective

Percutaneous balloon dilatation followed by long-term internal-external biliary catheter (IEBC) placement is the standard radiological management for postoperative hepaticojejunostomy (HJ) strictures. The treatment is considered successful when cholangiography shows a free flow of contrast across the anastomosis and the patient passes a "clinical test". However, these tests may not be suitable predictors of long-term successful treatment outcomes. The purpose of this study was to assess the utility of biliary manometry in the evaluation of successful treatment outcomes after HJ stricture dilatation and IEBC placement and its efficacy as a tool for early catheter removal.

Patients and methods

A total of 14 patients underwent percutaneous balloon dilatation of HJ strictures with IEBC placement. A two-to-three-month interval was maintained between sessions of exchanging or upsizing IEBCs. Biliary manometry was performed after a mean duration of 6.3 months. Intra-biliary pressure of <15 mmHg was considered as the success threshold.

Results

Among the 14 patients, 11 patients passed initial manometry and had their IEBCs removed and were followed up for a mean duration of 47.8 months. Of these, one patient developed biliary obstruction after six months and underwent repeat HJ stricture dilatation and long-term IEBC placement. Three patients failed manometry and underwent re-dilatation of HJ strictures with IEBC placement. Using Kaplan-Meier survival analysis, the probability of patients remaining stricture-free after HJ stricture dilatation was found to be 100% at three months and 91% at six, 12, 18, 24, 36, and 47.8 months.

Conclusion

Biliary manometry prevents subjective variations in determining treatment endpoints and helps to assess early catheter removal after percutaneous balloon dilatation of HJ strictures.

Evaluation and management of biliary complications after pediatric liver transplantation: pearls and pitfalls for percutaneous techniques

In pediatric liver transplantation, bile duct complications occur with a greater incidence than vascular anastomotic dysfunction and represent a major source of morbidity and mortality. While surgical re-anastomosis can reduce the need for retransplantation, interventional radiology offers minimally invasive and graft-saving therapies. The combination of small patient size and prevailing Roux-en-Y biliary enteric anastomotic techniques makes endoscopic retrograde cholangiopancreatography difficult if not impossible. Expertise in percutaneous management is therefore imperative. This article describes post-surgical anatomy, pathophysiology and noninvasive imaging of biliary complications. We review percutaneous techniques, focusing heavily on biliary access and interventions for reduced liver grafts. Subsequently we review the results and adverse events of these procedures and describe conditions that masquerade as biliary obstruction.

Timing of surgical repair of bile duct injuries after laparoscopic cholecystectomy: A systematic review

BACKGROUND

The surgical management of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC) is challenging and the optimal timing of surgery remains unclear. The primary aim of this study was to systematically evaluate the evidence behind the timing of BDI repair after LC in the literature.

AIM

To assess timing of surgical repair of BDI and postoperative complications.

METHODS

The MEDLINE, EMBASE, and The Cochrane Library databases were systematically screened up to August 2021. Risk of bias was assessed via the Newcastle Ottawa scale. The primary outcomes of this review included the timing of BDI repair and postoperative complications.

RESULTS

A total of 439 abstracts were screened, and 24 studies were included with 15609 patients included in this review. Of the 5229 BDIs reported, 4934 (94%) were classified as major injury. Timing of bile duct repair was immediate (14%, n = 705), early (28%, n = 1367), delayed (28%, n = 1367), or late (26%, n = 1286). Standardization of definition for timing of repair was remarkably poor among studies. Definitions for immediate repair ranged from < 24 h to 6 wk after LC while early repair ranged from < 24 h to 12 wk. Likewise, delayed (> 24 h to > 12 wk after LC) and late repair (> 6 wk after LC) showed a broad overlap.

CONCLUSION

The lack of standardization among studies precludes any conclusive recommendation on optimal timing of BDI repair after LC. This finding indicates an urgent need for a standardized reporting system of BDI repair.

Percutaneous or Endoscopic Treatment of Peripheral Bile Duct Leaks: Initial Experience with an Innovative Approach of Microcatheter-Delivered Argon Plasma Coagulation

PURPOSE

Biliary ductal injuries are challenging to treat, and often lead to severe morbidity and mortality. The first-line approach involves endoscopic retrograde cholangiopancreatography with sphincterotomy and, in case of refractory leakage, long-lasting percutaneous transhepatic biliary drainage, endoscopic or percutaneous injection of sclerosing agents and/or coiling can be used. We describe a treatment procedure using microcatheter-mediated percutaneous or endoscopic argon plasma coagulation (APC).

MATERIALS AND METHODS

Three patients (7-year-old male, 14-year-old male, 81-year-old female) with refractory postsurgical and/or post-traumatic bile leaks underwent percutaneous (n = 2) or endoscopic (n = 1) APC through a detachable microcatheter.

RESULTS

The procedure was technically feasible in all patients. Postoperative imaging showed complete occlusion of biliary leakage. The technique was uneventful intraoperatively with no adverse events occurring during recovery or follow-up.

CONCLUSION

Our initial experience demonstrates that refractory bile duct leaks may be successfully treated with microcatheter-mediated APC endoscopically or percutaneously. Further research is needed to confirm the safety, efficacy, and clinical indications for this innovative technique.

Percutaneous management of postoperative Bile leak after hepato-pancreato-biliary surgery: a multi-center experience

BACKGROUND

Bile leak (BL) after hepato-pancreato-biliary (HPB) surgery is associated with significant morbidity and mortality. Aim of this study was to evaluate effectiveness and safety of percutaneous transhepatic approach (PTA) to drainage BL after HPB surgery.

METHODS

Between 2006 and 2018, consecutive patients who were referred to interventional radiology units of three tertiary referral hospitals were retrospectively identified. Technical success and clinical success were analyzed and evaluated according to surgery type, BL-site and grade, catheter size and biochemical variables. Complications of PTA were reported.

RESULTS

One-hundred-eighty-five patients underwent PTA for BL. Technical success was 100%. Clinical success was 78% with a median (range) resolution time of 21 (5-221) days. Increased clinical success was associated with patients who underwent hepaticresection (86%,p = 0,168) or cholecystectomy (86%,p = 0,112) while low success rate was associated to liver-transplantation (56%,p < 0,001). BL-site,grade, catheter size and AST/ALT levels were not associated with clinical success. ALT/AST high levels were correlated to short time resolution (17 vs 25 days, p = 0,037 and 16 vs 25 day, p = 0,011, respectively) Complications of PTA were documented in 21 (11%) patients.

CONCLUSION

This study based on a large cohort of patients demonstrated that PTA is a valid and safe approach in BL treatment after HPB surgery.

Disseminated Coccidioidomycosis to the Gallbladder

Coccidioidomycosis is an infection caused by inhalation of arthroconidia produced by dimorphic fungi in the genus Coccidioides. Forty percent of patients will develop an influenza-like illness with symptoms suggestive of a mild and self-limited respiratory infection; however, 5% of these individuals will develop extrapulmonary disseminated disease. An immunocompromised patient presented with right upper quadrant pain, ultrasound with pericholecystic fluid, in which a percutaneous cholecystostomy contained biliary fluid that grew the fungus Coccidioides immitis. Patient was initiated on intravenous amphotericin therapy and was followed closely with postoperative bile drainage with eventual laparoscopic cholecystectomy. We present a very rare case of disseminated coccidioidomycosis to the gallbladder.

MRI evaluation of bile duct injuries and other post-cholecystectomy complications

Laparoscopic cholecystectomy is one of the most common procedures performed each year and can be associated with various post-operative complications. Imaging is integral to diagnosis and management of patients with suspected cholecystectomy complications, and a thorough understanding of normal and abnormal biliary anatomy, risk factors for biliary injury, and the spectrum of adverse events is crucial for interpretation of imaging studies. Magnetic resonance cholangiography (MRC) enhanced with hepatobiliary contrast agent is useful in delineating biliary anatomy and pathology following cholecystectomy. In this article, we provide a protocol for contrast-enhanced MR imaging of the biliary tree. We also review the classification and imaging manifestations of post-cholecystectomy bile duct injuries in addition to other complications such as bilomas, retained/dropped gallstones, and vascular injuries.

The Risk Assessment and Clinical Research of Bile Duct Injury After Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma

Purpose

To retrospectively evaluate the risk factors and the clinical outcomes of bile duct injury after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) and to evaluate factors that aid clinical detection and subsequent treatment of the injured bile duct.

Materials and Methods

All patients undergoing TACE for HCC were retrospectively reviewed for identification of bile duct injury. The clinical spectrum of all the patients analyzed including patients’ demographics, laboratory data, radiologic imaging and mode of treatment.

Results

From January 2015 to December 2017, a total of 21 patients (4.3%) out of 483 patients with 693 TACE procedures were identified to have bile duct injury at our single institution. There were 17 males and 4 females, with a mean age of 59.8±11.6 years (range 34–84). About 14.3% (3/21) patients show the high-density shadow around the bile duct wall in one week non-enhanced CT, and 76.2% (16/21) cases ALP>200 U/L, all these patients showed bile duct injury on the subsequent follow-up CT. Post-TACE follow-up blood biochemistry showed that alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GGT) increased significantly compared with pre-TACE level. The incidence of various types of bile duct injuries on CT was intrahepatic bile duct dilatation (57.1%), biloma (25.7%) and hepatic hilar biliary strictures (17.1%), respectively. Patients with prior hepatectomy as well as proximal arterial chemoembolization carried a higher risk of post-TACE bile duct injury in terms of microvascular damage to the peribiliary capillary plexus.

Conclusion

Bile duct injury complicating TACE is not caused by a single factor, but by a variety of factors, and is closely related to the microvascular compromise of the bile ducts and subsequent chronic biliary infection. Lipiodol deposited along the bile duct wall and the sharp rise of ALP>200 U/L in one week after TACE can predict bile duct injury and early intervention may prevent the occurrence of serious complications. The probability of bile duct injury in patients with prior hepatectomy and proximal arterial chemoembolization increases significantly.

The Role of Interventional Radiology in Treatment of Patients with Acute Trauma: A Pictorial Essay

Acute trauma is a common cause of mortality in individuals aged < 40 years. As organ preservation has become important in treating trauma patients, the treatment is shifting from surgical management to non-operative management. A multidisciplinary team approach, including interventional radiology (IR), is essential for the optimal management of trauma patients, as IR plays an important role in injury evaluation and management. IR also contributes significantly to achieving the best clinical outcomes in critically ill trauma patients. This pictorial essay aims to present and summarize various interventional treatments in trauma patients requiring critical care.

A Case of Candidal Infection of Large Biloma After CT-Guided Liver Biopsy Confirming Autoimmune Hepatitis

Bilomas are unexpected post-procedural complications of cholecystectomies, hepatic resections, endoscopic retrograde cholangiopancreatography, and-rarely-liver biopsies. While uncommon, this should remain high on the differential in a patient presenting with sudden postop sepsis even in the absence of significant liver injury. Diagnosis involves coordination between interventional radiology, gastroenterology, and internal medicine. This involves a precise clinical history, invasive radiological techniques, and advanced interventional endoscopic solutions for diagnosis and treatment. This is a case of a biloma that occurred as a consequence of a post-hepatic biopsy and resulted in fungal infection, rather than its more common bacterial counterpart. Due to the unusual circumstances, a more circuitous route to the correct diagnosis and treatment was undertaken.

ACR Appropriateness Criteria® Radiologic Management of Biliary Obstruction

Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Long-term outcomes of endoscopic treatment of aberrant hepatic duct injuries after cholecystectomy

BACKGROUND AND AIMS

Right aberrant hepatic ducts are an anatomic variant with clinical relevance because of the risk of injury during cholecystectomy. Treatment options for aberrant hepatic duct injuries are not standardized. This study aims to analyze the long-term results of endoscopic treatment of aberrant hepatic duct lesions.

METHODS

Patients who underwent ERCP for aberrant hepatic duct lesions were retrospectively identified. Demographic data, type of aberrant duct lesion according to the Strasberg classification, type of treatment (number of plastic stents inserted, treatment duration, and number of ERCPs), and adverse events were recorded. Follow-up was obtained by telephone contact or medical examinations.

RESULTS

Between January 1996 and March 2019, 32 patients (78% women, mean age 51.7 years) with aberrant hepatic duct injuries underwent ERCP at our Endoscopy Unit. Six patients had Strasberg type B lesions, 11 patients had type C, and 8 patients had type E5, and 7 patients had a stenosis of the aberrant duct. A mean of 3.7 biliary plastic stents per patient were used; mean treatment duration was 6.3 months. All patients with isolated aberrant duct stenosis and 1 of 6 patients (17%) with type B Strasberg lesions achieved patency. Ten of 11 patients (91%) with type C Strasberg lesions achieved duct recanalization. After a mean follow-up of 109.3 ± 61.2 months, 29 of 32 patients (91%) were asymptomatic; 1 underwent surgery for recurrent cholangitis, 1 received a new endoscopic procedure because of cholangitis, and 1 reported episodic biliary colic without an increase in liver function test values and was successfully managed with a low-fat diet.

CONCLUSIONS

An endoscopic approach to aberrant hepatic duct lesions after cholecystectomy can be considered an effective first-line therapy.

Percutaneous Transhepatic Removal of Migrated Biliary Stent from a Chronic Biloma Cavity

Iatrogenic foreign bodies are a challenging complication to both the interventional radiologist and patient, resulting in impaired quality of life and substantial financial cost. The case report describes a successful percutaneous transhepatic removal of an intra-abdominal foreign body. A 72-year-old man underwent surgery for placement of a retrievable covered stent for refractory bile leakage after left hemihepatectomy. Three days after placement, stent folding and migration into a chronic biloma cavity occurred via the bile leakage site. By using a balloon catheter technique, the folded stent could be straightened and repositioned into the bile duct to minimize stent-strut injury during retrieval. The interventional approach could be a valid treatment option for intra-abdominal foreign bodies, as well as intravascular foreign bodies. A thorough understanding of devices and techniques can provide the interventional radiologist with valuable information regarding procedural planning and the management of iatrogenic foreign bodies.

Imaging of Acute Hepatobiliary Dysfunction

Abdominal pain is a common cause for emergency department visits in the United States, and biliary tract disease is the fifth most common cause of hospital admission. Common causes of acute hepatobiliary include gallstones and its associated complications and multiple other hepatobiliary etiologies, including infectious, inflammatory, vascular, and neoplastic causes. Postoperative complications of the biliary tract can result in an acute abdomen. Imaging of the hepatobiliary tree is integral in the diagnostic evaluation of acute hepatobiliary dysfunction, and imaging of the biliary tree requires a multimodality approach utilizing ultrasound, computed tomography, nuclear medicine, and MR imaging.

Reliable reconstruction of the complex high-location bile duct injury: a novel hepaticojejunostomy

BACKGROUND

This study aimed to propose a novel surgical reconstruction technique for complex high-location bile duct injury (CHBDI).

METHODS

There were eight patients with CHBDI underwent the novel hepaticojejunostomy between Feb 2015 and Feb 2017. Seven patients underwent a primary operation and found CHBDI postoperatively in the inferior hospitals referred to our center. And four of them had received hepaticojejunostomy, but the results were not satisfying. One patient (No.8) with radiographically diagnosed hilar cholangiocarcinoma came to our center for surgical treatment and underwent the novel hepaticojejunostomy technique because CHBDI was found in operation. Perioperative and follow-up data of these patients were retrospectively reviewed.

RESULTS

The mean age was 47.6 ± 10.7 years, and there was four female. The mean range of time between the injury and the repair operation in our center was 6.3 ± 4.8 months. All repair operations using the novel hepaticojejunostomy technique in our center were successfully performed. No postoperative complications, including biliary fistula, restenosis, peritonitis, and postoperative cholangitis was observed. Besides, no evidence of biliary stenosis or biliary complications happened during the follow-up (median 28 months).

CONCLUSIONS

The novel hepaticojejunostomy is a reliable and convenient technique for surgical repair of multiple biliary ductal openings like CHBDI.

Imaging of Abdominal Postoperative Complications

We present a case-based review of abdominal postoperative complications, organized by organ system affected, including wound/superficial, hepatobiliary, pancreatic, gastrointestinal, genitourinary, and vascular complications. Both general complications and specific considerations for certain types of operations are described, as well as potential pitfalls that can be confused with complications. Representative cases are shown using all relevant imaging modalities, including CT, fluoroscopy, ultrasound, MRI, and nuclear medicine. Management options are also described, highlighting those that require radiologist input or intervention.

Cholecystohepatic Duct: A Biliary Duct Variant Resulting in Postcholecystectomy Bile Leak-Case Report and Review of Normal and Common Variant Biliary Anatomy

Although relatively infrequent, bile duct leaks are among the primary complications of hepatobiliary surgery and cholecystectomy given the large number of these operations performed annually around the world. Variant biliary anatomy increases the risk of surgical complications, especially if unrecognized on preoperative imaging or intraoperatively. Presented here is a case of a patient with an unrecognized cholecystohepatic duct at the time of surgery leading to bile leak after cholecystectomy. Numerous factors made for a technically difficult surgery with obscuration of the true anatomy, ultimately resulting in transection of the cholecystohepatic duct. Understanding normal and variant biliary anatomy will help prevent avoidable complications of hepatobiliary surgery.

Excision of a part of the bile duct as an iatrogenic injury typical for laparoscopic cholecystectomy - characteristics, treatment and long-term results, based on own material

Introduction

Cholecystectomy is associated with the risk of bile duct injury (BDI). The nature of the injury in laparoscopic cholecystectomy (LC) cases seems to be more serious.

Aim

We present an analysis of long-term results of the treatment of patients who underwent operations at our department due to iatrogenic excision of a part of the bile duct (EPBD).

Material and methods

Out of all 120 patients treated for BDI in our department we selected a group of 40 with EPBD. In all cases the corrective operation was hepaticojejunostomy. The median follow-up time was 157 (56–249) months. We evaluated risk factors for EPBD during LC compared to open cholecystectomy (OC).

Results

Among bile duct injuries referred to our centre, EPBD occurred more frequently during LC (46.7%) compared to OC (11%), p < 0.001. Injuries located in the hepatic hilum occurred more often in the case of LC (68.6%) than OC (20%), p = 0.056. We did not find a difference in the frequency of EPBD between LC and OC groups depending on the presence of acute or chronic cholecystitis. The narrow common hepatic duct was reported more frequently in the LC (68.6%) vs. OC (20%) group, p = 0.056. Satisfactory long-term reconstructive treatment results were observed in 36 (90%) of 40 patients.

Conclusions

Excision of a part of the bile duct occurs more often during LC than OC. It is often located in the hepatic hilum. Presence of a narrow common hepatic duct is a risk factor for EPBD during LC. Large diameter hepaticojejunostomy is a reconstructive procedure that promises good long-term results.

Management of Biliary Strictures: State-of-the-Art Review

Biliary strictures can be broadly classified as benign or malignant. Benign biliary strictures are most commonly iatrogenic in nature and are a consequence of hepatobiliary surgery. Cholangiocarcinoma and adenocarcinoma of the pancreas are the most common causes of malignant biliary obstruction. This article reviews state-of-the-art minimally invasive techniques used to manage these strictures. In addition, the roles of (a) recently introduced biodegradable biliary stents in the management of benign biliary strictures and (b) intraprocedural imaging and navigation tools, such as cone-beam CT, in percutaneous reconstruction of the biliary-enteric anastomosis are discussed.

Combined surgical and interventional radiological treatment for biliary leakage following iatrogenic biliary obstruction

Biliary leakage is a challenging complication when managing the bile duct strictures. The etiology of benign strictures of the biliary tree may have different etiologies but iatrogenic is the most common, with relevant increase after introduction of laparoscopic procedures.

Interventional radiologist plays a key role, both in diagnosis and treatment of biliary strictures and leakage.

We report on a case of a 39-year-old woman affected by abdominal pain and jaundice after laparoscopic cholecystectomy; jaundice was caused by surgical clipping of the common bile duct. The combined management by surgeon and interventional radiologist, consisting of removal of surgical clip and percutaneous management of biliary leakage, successfully resolved the leakage with clinical success.

Hemobilia: An Uncommon But Notable Cause of Upper Gastrointestinal Bleeding

GOAL AND BACKGROUND

A literature review to improve practitioners' knowledge and performance concerning the epidemiology, diagnosis, and management of hemobilia.

STUDY

A search of Pubmed, Google Scholar, and Medline was conducted using the keyword hemobilia and relevant articles were reviewed and analyzed. The findings pertaining to hemobilia etiology, investigation, and management techniques were considered and organized by clinicians practiced in hemobilia.

RESULTS

The majority of current hemobilia cases have an iatrogenic cause from either bile duct or liver manipulation. Blunt trauma is also a significant cause of hemobilia. The classic triad presentation of right upper quadrant pain, jaundice, and upper gastrointestinal bleeding is rarely seen. Computed tomography and magnetic resonance imaging are the preferred diagnostic modalities, and the preferred therapeutic management includes interventional radiology and endoscopic retrograde cholangiopancreatography. Surgery is rarely a therapeutic option.

CONCLUSIONS

With advances in computed tomography and magnetic resonance imaging technology, diagnosis with these less invasive investigations are the favored option. However, traditional catheter angiography is still the gold standard. The management of significant hemobilia is still centered on arterial embolization, but arterial and biliary stents have become accepted alternative therapies.

Leakage of Hepaticojejunal Anastomosis: Radiological Interventional Therapy

BACKGROUND

Hepaticojejunostomy is an established procedure accompanying liver resection as well as hepatobiliary and pancreatic surgery. Typical complications requiring radiological intervention are abscesses and anastomosis leakage. Biliary obstruction and strictures are less frequent indications for interventional radiology since many of them can be treated endoscopically.

METHODS

Depending on anatomic location, underlying etiology, and complication of leakage, different procedures of interventional radiology are performed: treating abscesses through percutaneous abscess drainage (PAD), handling biliary leakage by percutaneous transhepatic biliary drainage (PTBD) after percutaneous transhepatic cholangiography (PTC), or rarely performed percutaneous stent implantation and internalization after PTC and PAD to treat biliary strictures or to cover the leak. A selective literature search was performed, taking into account recent papers of radiological interventions concerning leakage of hepaticojejunostomy.

RESULTS

Different radiological interventions for the treatment of potentially devastating complications after hepaticojejunostomy are recommended. PAD and PTBD serve either as a definite treatment or as bridging therapy until re-surgery is performed. Complications mainly concern uncontrollable bleeding during the intervention.

CONCLUSION

Radiological interventions are safe and usable if the indication is meticulously chosen. PAD is one of the most commonly performed procedures by interventional radiologists and a well-established and safe procedure. PTC, PTBD, and biliary stent implantation are important procedures which are required if endoscopic interventions failed or cannot be performed due to postoperatively changed anatomical structures.

Clinical outcomes in patients with bile leaks treated via ERCP with regard to the timing of ERCP: a large multicenter study

BACKGROUND AND AIMS

Postsurgical or traumatic bile duct leaks (BDLs) can be safely and effectively managed by endoscopic therapy via ERCP. The early diagnosis of BDL is important because unrecognized leaks can lead to serious adverse events (AEs). Our aim was to evaluate the relationship between timing of endotherapy after BDL and the clinical outcomes, AEs, and long-term results of endoscopic therapy.

METHODS

We conducted a multicenter, retrospective study on patients with BDLs who underwent ERCP between 2006 and 2014. Data were assembled on patient demographics, etiology of BDL, and procedural details. Endotherapy for BDLs were classified a priori into 3 groups based on timing of ERCP from time of biliary injury: within 1 day of BDL, on day 2 or 3 after BDL, and greater than 3 days after BDL. The relationship among timing of ERCP after BDL injury and outcomes, procedure-related AEs, and patient AEs and mortality were evaluated.

RESULTS

From February 2006 to June 2014, 518 patients (50% male; mean age, 51.7 years) underwent ERCP for therapy of BDLs. The etiology of the BDL was laparoscopic cholecystectomy (70.7%), post-liver transplantation (11.2%), liver resection (14.1%), trauma (2.5%), and other causes (1.5%). Endotherapy was performed by placing a transpapillary stent alone (73.5%) or with a sphincterotomy (26.5%). The timing of ERCPs was as follows: ≤1 day = 57 patients, day 2 or 3 = 140 patients, and >3 days = 321 patients. There was no statistical difference in patient demographics, etiology/site of BDL, or type of endotherapy performed among the 3 groups. On multivariate analysis there was no statistically significant difference in BDL success rate for ERCPs performed within 1 day compared with those performed on day 2 or 3 or after 3 days of bile duct injury (91.2%, 90%, and 88.5%, respectively; P = .77). Similarly, there was no significant difference in the overall patient AE rate among the 3 groups (21.1%, 22.9%, and 24.6%, respectively; P = .81). AEs in men occurred significantly more frequently when compared with women, even after adjusting for age, BDL etiology, and location of leak (27.6% vs 19.9%; OR, 1.53; P = .04). Patients whose BDL was due to a cholecystectomy had a lower AE and mortality rate compared with those who had biliary injury from other etiologies (OR, .42; P < .001).

CONCLUSIONS

The overall success rates and AEs after ERCP were not dependent on the timing of the procedure relative to the discovery of the bile leak. This suggests that ERCP in these patients can usually be performed in an elective, rather than an urgent, manner.

Management for a complicated biliary stricture after iatrogenic bile duct injury

Bile duct injury (BDI) remains to be a serious complication of biliary surgery. Biliary stricture is likely to occur in cases without proper management of BDI, may be causing such severe complications as repeated strictures, cholangitis or impairment to liver function. Here, we reported a 69-year-old man with a one-more-year history of recurrent cholangitis caused by iatrogenic BDI. The patient underwent a reconstruction of choledochojejunostomy, with liver quadrate lobectomy, and hilar cholangioplasty. The procedure was difficult, but the recovery was smooth. Only through comprehensive pre-operative evaluation and meticulous intraoperative manipulate, the technical challenge of re-operation for complicated biliary stricture after BDI should be easily addressed.

Iatrogenic, blunt, and penetrating trauma to the biliary tract

Iatrogenic and traumatic bile leaks are uncommon. However, given the overall increase in number of hepatobiliary surgeries and the paradigm shift toward nonoperative management of patients with liver trauma, they have become more prevalent in recent years. Imaging is essential to establishing early diagnosis and guiding treatment as the clinical signs and symptoms of bile leaks are nonspecific, and a delay in recognition of bile leaks portends a high morbidity and mortality rate. Findings suspicious for a bile leak at computed tomography or ultrasonography include free or contained peri- or intrahepatic low density fluid in the setting of recent trauma or hepatobiliary surgery. Hepatobiliary scintigraphy and magnetic resonance cholangiopancreatography (MRCP) with hepatobiliary contrast agents can be used to detect active or contained bile leak. MRCP with hepatobiliary contrast agents has the unique ability to reveal the exact location of bile leak, which often governs whether endoscopic management or surgical management is warranted. Percutaneous transhepatic cholangiography and fluoroscopy via an indwelling catheter that is placed either percutaneously or surgically are useful modalities to guide percutaneous transhepatic biliary drain placement which can provide biliary drainage and/or diversion in the setting of traumatic biliary injury. Surgical treatment of a bile duct injury with Roux-en-Y hepaticojejunostomy is warranted if definitive treatment cannot be accomplished through percutaneous or endoscopic means.

Diagnosis and Management of Postoperative Biliary Leaks

Postoperative biliary leaks have become more common in the past three decades since the development of laparoscopic biliary surgery. The role of the radiologist and interventional radiologist is important in the diagnosis and treatment of such complications, and can play an adjunctive role in the definitive surgical repair. Ultrasound, computed tomography, magnetic resonance cholangiopancreatography, nuclear medicine cholescintigraphy studies, and percutaneous transhepatic cholangiograms (PTC) are the various imaging modalities used for diagnosis. Interventional radiology treatment involves percutaneous drainage of bilomas, characterization of the biliary tree and assessment of the site of ductal injury with PTC, and biliary diversion with external biliary drainage.

Percutaneous transcatheter embolisation of active haemorrhage following radiofrequency ablation of hepatocellular carcinoma

A 72-year-old woman with hepatitis C virus cirrhosis underwent a surveillance ultrasound examination which identified a new hepatic lesion. A workup triphasic CT examination demonstrated a 3.7 cm lesion at the hepatic dome with arterial enhancement and portal venous washout consistent with hepatocellular carcinoma. She subsequently proceeded for treatment with radiofrequency ablation (RFA). RFA was technically successful, but the patient became hypotensive and tachycardic postprocedure. A CT angiogram demonstrated active arterial intraperitoneal haemorrhage from the RFA site. The patient returned to the interventional suite for catheter angiography which confirmed the presence of active haemorrhage from the hepatic arterial branch supplying segment VIII. The bleeding vessel was selectively catheterised with a microcatheter, and successfully embolised with 250-355 µm polyvinyl alcohol particles.