Percutaneous transhepatic embolization of biliary leakage with N-butyl cyanoacrylate

Embolization of an incomplete isolated right segmental hepatic duct injury (incomplete IRSHDI)-A case report

Iatrogenic bile duct injuries remain a substantial problem in gastrointestinal surgery, especially if discovered later in the postoperative period. Herein, we report a case of an unusual bile leak following laparoscopic cholecystectomy consisting of an isolated right segmental hepatic duct injury of segment 5 together with an additional bile leak of a small duct connecting the gallbladder fossa with the common bile duct. We call this situation an incomplete isolated right segmental hepatic duct injury. Patient presented with infected biloma 2 weeks after laparoscopic cholecystectomy. After percutaneous drainage of the biloma and antibiotic therapy the complex biliary fistula was closed first with coil embolization of the small connection to the common bile duct and then with both antegrade and retrograde histoacryl embolization of the hereby created complete isolated right segmental hepatic duct injury in a single session. Patient was discharged the same day and recovered without complication or recurrence.

Role of interventional radiology in the management of complex pediatric surgical cases

INTRODUCTION

Minimally-invasive techniques offered by interventional radiology (IR) are really helpful in the management of challenging surgical cases. The current report highlights a series of four complex pediatric surgical cases which were successfully managed by specific image-guided techniques.

CASE PRESENTATION

The first two cases in the present report were infants. One of them had a complicated type-1 choledochal cyst (obstructive jaundice and cholangitis) and was optimized with preoperative percutaneous transhepatic biliary drainage (PTBD) under fluoroscopic guidance. The other child had bilateral ureteropelvic junction obstruction and presented with urosepsis. Due to failure of retrograde stenting on one side, image-guided percutaneous nephrostomy and antegrade stenting were performed. The third and fourth cases had suffered blunt trauma to the abdomen. While one of them developed multiple pseudoaneurysms and arterioportal fistulae in the liver, the other had transection of the right posterior sectoral duct. Angioembolization of the pseudoaneurysms and embolization of the right posterior sectoral duct were performed for them under image-guidance respectively. The post-procedural course of all the above children was uneventful.

DISCUSSION

Image-guided minimally invasive procedures are associated with less post-procedural pain, early recovery, and better cosmetic outcomes. In specific scenarios, they may even obviate the need for surgical intervention, thereby reducing the overall morbidity.

CONCLUSION

Interventional radiology offers safe and effective alternatives to operative interventions. They are especially useful in the backdrop of significant morbidities like cholangitis, urosepsis, and trauma.

Embolization of extrahepatic biliary leakage using NBCA

Biliary fistula and bile leakage are complications that can occur during hepato-biliary or intestinal surgery and percutaneous biliary intervention. In some cases, spontaneous resolution is possible but more often re-intervention (surgical or percutaneous) is necessary. We present the case of a 45 y-o male patient who underwent duodenocefalopanreasectomy (Whipple procedure) with bilio-digestive anastomosis for adenoma of the duodenal papilla of Vater, complicated by the formation of a fistula through the bilio-digestive anastomosis. Conservative treatment with percutaneous biliary drainage was attempted in order to promote spontaneous resolution of the fistula. The persistence of the fistula brought the patient to treatment through interventional techniques. Sealing of the bilio-peritoneal fistula was obtained using N-butil-Cyanoacrylate .

The role of imaging in surgical planning for liver resection: what the radiologist need to know

The management of patients undergoing surgical resection for liver malignancies requires a multidisciplinary team, including a dedicated radiologist. In the preoperative workup, the radiologist has to provide precise, relevant information to the surgeon. This requires the radiologist to know the basics of surgical techniques as well as liver surgical anatomy in order to help to avoid unexpected surgical scenarios and complications. Moreover, virtual resections and volumetries on radiological images will be discussed, and basic concepts of postoperative liver failure, regeneration, and methods for hypertrophy induction will be provided. (www.actabiomedica.it)

Hepatic tumors: pitfall in diagnostic imaging

On computed tomography (CT) and magnetic resonance imaging (MRI), hepatocellular tumors are characterized based on typical imaging findings. However, hepatocellular adenoma, focal nodular hyperplasia, and hepatocellular carcinoma can show uncommon appearances at CT and MRI, which may lead to diagnostic challenges. When assessing focal hepatic lesions, radiologists need to be aware of these atypical imaging findings to avoid misdiagnoses that can alter the management plan. The purpose of this review is to illustrate a variety of pitfalls and atypical features of hepatocellular tumors that can lead to misinterpretations providing specific clues to the correct diagnoses. (www.actabiomedica.it)

Basic embolization techniques: tips and tricks

Good knowledge of the various approaches of embolization of peripheral bleedings and different embolic materials available is of paramount importance for successful and safe embolization. We review and illustrate the main endovascular and percutaneous techniques used for embolization, along with the characteristics of the different embolic materials, and the potential complications.

Bilio-cutaneous fistula obliteration with NBCA

Biliary fistula and bile leakage are complications that can occur during hepato-biliary surgery (both open and laparoscopic) and percutaneous biliary intervention. In some cases, spontaneous resolution is documented but more often re-intervention (surgical or percutaneous) is necessary. We present the case of a male patient who underwent right hepatectomy with bilio-digestive anastomosis for a cholangiocarcinoma which developed a bilo-cutaneous fistula through the path of a previously inserted percutaneous transhepatic drainage. Sealing of bilo-cutaneous fistula was obtained using N-butil-Cyanoacrylate. This technique has already been reported in some papers as a useful tool for biliary tree obliteration; however, to our knowledge, no cases describing the use of glue to seal a sub-cutaneous route are available in literature.

Biliary injuries after pancreatic surgery: interventional radiology management

Bile duct injuries are among the most feared complications after pancreatic surgery. Most of these surgical complications are related to iatrogenic injuries and include bile leakage, biliary duct obstruction or stricture and infection. A wide range of Interventional Radiology treatment options are currently available. The options include percutaneous transhepatic cholangiography (PTC), percutaneous transhepatic biliary drainage (PTBD), percutaneous balloon dilatation and stenting, image-guided percutaneous abscess drainage. The purpose of this review is to describe the current evidence in this continuously evolving field.

Percutaneous Biliary Interventions

Biliary drainage is important in the care of patients with benign and malignant biliary obstruction. Careful preprocedure evaluation of high-quality cross-sectional imaging and inventory of symptoms are necessary to determine whether a percutaneous, endoscopic, or surgical approach is most appropriate. High bile duct obstruction is usually best managed percutaneously; a specific duct can be targeted and enteric contamination of isolated ducts can be avoided. Options for percutaneous biliary intervention include external or internal/external biliary drainage, stent placement, biliary stone retrieval, and bile duct biopsy. Preprocedure evaluation, technique, and indications for percutaneous intervention in benign and malignant diseases are summarized.

A novel endoscopic treatment of major bile duct leak

INTRODUCTION

Bile leak is a serious complication of hepatobiliary surgery. The incidence has remained the same over the last decade despite significant improvement in the results of liver surgery.

PRESENTATION OF CASE

A 21-year-old man was a passenger in a motor vehicle and sustained a blunt abdominal trauma in a high-speed collision leading to major liver laceration. He had right lobe hepatectomy complicated by major bile leak. He was not fit for further surgery and he, therefore, had ERCP and obliteration of the leaking bile duct using a combination of metallic coil and N-butyl cyanoacrylate.

DISCUSSION

Endoscopic therapy has become the modality of choice in the treatment of biliary tract injuries. Different modalities of management of persistent bile leak such as sphincterotomy, plastic biliary stents, and nasobiliary drainage have been described. Obliteration of bile duct leak using N-butyl cyanoacrylate and coil embolization has been described but most of these reports used the percutaneous transhepatic approach.

CONCLUSION

In this paper, we describe the second reported case in English literature of a novel endoscopic technique using a combination of metallic coil embolization and N-butyl cyanoacrylate in a patient with major bile leak who was not a candidate for surgery as well as a third report of the late complication of coil migration to the common bile duct.

Use of amplatzer vascular plug to treat a biliary cutaneous fistula

Several substances have been used in an attempt to sclerose biliary ducts associated with persistent biliary-cutaneous fistula (BCF). The AMPLATZER Vascular Plug (AVP; AGA Medical, USA) system is a recently developed endovascular occlusion device, introduced as an alternative to permanent embolic materials (metallic coils or acrylic glue), in the occlusion of large and medium-calibre arteries and veins. We report a successful use of the AVP to embolize BCF, developed after the removal of an internal-external biliary drainage.