(Radiology. 1999;211:345-348.)
© RSNA, 1999
Vascular and Interventional Radiology |
Biliary Leaks: Treatment by Means of Percutaneous Transhepatic Biliary Drainage1
Olivier Ernst, MD,
Géraldine Sergent, MD,
Didier Mizrahi, MD,
Olivier Delemazure, MD and
Claude L'Herminé, MD
1 From the Department of Radiology, Centre Hospitalier Universitaire de Lille, 1 place de Verdun, F-59037 Lille, France. Received March 25, 1998; revision requested June 19; final revision received September 16; accepted October 26. Address reprint requests to O.E.
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Abstract
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PURPOSE: To evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks.
MATERIALS AND METHODS: Sixteen patients with a biliary leak involving either the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2) were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to severe acute necrotizing pancreatitis in six patients, while 10 patients had postoperative leak. Percutaneous transhepatic biliary drainage was performed with a 12-F catheter, with two series of side holes positioned on both sides of the extravasation to divert bile flow away from the defect.
RESULTS: In 13 patients, the biliary leak healed after drainage (mean duration, 78 days). In four of these patients, a slight residual narrowing of the bile duct was treated by means of either balloon dilation (n = 2) or balloon dilation followed by insertion of a metallic stent (n = 2). All 13 patients remained cured (mean follow-up, 38 months). Two patients with severe acute necrotizing pancreatitis died of complications unrelated to the biliary leak. Vascular complications occurred in two patients, one of whom died after surgical drainage of a subcapsular hematoma.
CONCLUSION: Biliary leaks can be treated successfully by means of percutaneous transhepatic biliary drainage. The procedure is particularly useful when surgical or endoscopic management has failed.
Index terms: Bile ducts, injuries, 76.284 • Bile ducts, interventional procedure, 76.1263, 76.1267 • Bile ducts, leakage, 76.1263, 76.284 • Pancreatitis, 77.291
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Introduction
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Postoperative biliary leaks usually occur as a complication of laparoscopic cholecystectomy or enterobiliary anastomosis. They are usually treated by means of either surgical repair (1) or endoscopic biliary drainage (2,3). Surgical repair and endoscopic management are, in some cases, either impossible or unsuccessful, particularly in patients with large postoperative biliary duct defects or biliary leaks associated with severe acute necrotizing pancreatitis (4,5). In these conditions, the bile flow can easily be diverted away from the defect in the bile duct through percutaneous transhepatic biliary drainage in the same way that a ureteral leak can be treated by using a nephroureteral catheter (6–8). The aim of this study was to evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks.
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MATERIALS AND METHODS
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Patients
From 1990 to 1997, 16 patients (nine men, seven women; age range, 28–73 years; mean, 55 years) with biliary leak were referred to our department and treated by means of percutaneous transhepatic biliary drainage. Biliary extravasation was evidenced through a defect involving the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2). In 13 patients, percutaneous transhepatic biliary drainage was performed after attempting either surgical repair (n = 5) or endoscopic treatment (n = 8).
Ten patients (62%) had a leak after a bile duct injury from laparoscopic cholecystectomy (n = 8) or hepaticojejunostomy associated with duodenopancreatectomy (n = 2). Leak was suspected because of persistent bilious-looking drainage from the surgical drain (n = 4) or because of bile peritonitis (n = 2) or perihepatic biloma detected at postoperative computed tomography (n = 6). In four patients, the bile leak persisted after surgical repair was attempted 2–6 days (mean, 4 days) after the first surgery. Six patients underwent endoscopic retrograde cholangiopancreatography (ERCP), which depicted the biliary leak: Endoscopic sphincterectomy was performed, but insertion of a stent to achieve biliary drainage failed.
In six patients, the biliary leak was due to severe acute necrotizing pancreatitis with abscess formation treated by means of either percutaneous or surgical drainage. Biliary leak was suspected because the drainage produced bile. Injection of 10–20 mL of ioxitalamate meglumine (Telebrix 30 Meglumine; Guerbet, Aulnay-sous-Bois, France) through these percutaneous or surgical drains resulted in opacification of the common bile duct, thus demonstrating the biliary leak. Endoscopic sphincterectomy was performed in two patients and surgical sphincterectomy was performed in one, but these treatments were unsuccessful.
Procedure
Percutaneous transhepatic biliary cholangiography was initially performed by using a 22-gauge Chiba needle (Nycomed, Paris, France) to inject the contrast medium from the right intercostal approach. A right or left approach for the percutaneous transhepatic biliary drainage was chosen depending on biliary anatomy, bile leak topography, and the possibility of puncturing a dilated intrahepatic bile duct. Catheterization of intrahepatic bile ducts was performed in standard fashion. A guide wire was advanced through the biliary system into the duodenum. When this was achieved, a 6.5-F biliary drainage catheter (polyethylene pigtail; Biosphere Medical, Louviers, France) was inserted for 3 days of drainage. All drainage procedures were performed with the administration of broad-spectrum antibiotics. In three patients, percutaneous drainage of a large perihepatic biloma was also performed.
Three days after the drainage procedures were performed, the 6.5-F catheter was replaced with a 12-F catheter (Medi-tech Straight Drain; Boston Scientific, Natick, Mass) with two series of side holes separated by a blind segment. The side holes were made according to the location of the defect shown at cholangiography. The 12-F catheter was positioned within the bile ducts to have the upper series of side holes in the intrahepatic bile ducts above the leak and the lower series in the duodenum to obtain a complete exclusion of the leak. Bilateral biliary drainage was used if the bile leak involved the biliary confluence.
As soon as adequate internal biliary drainage was attained and the leak was excluded, the catheter was closed to avoid protein and calorie malnutrition and fluid and electrolyte depletion. As a control procedure, cholangiography was performed every month during the treatment. The catheter was removed when cholangiography showed the leak had healed without residual stenosis. If there was residual narrowing at the site of extravasation, balloon dilation was performed followed by insertion of an endoprosthesis when necessary (9).
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RESULTS
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Cholangiography and drainage were successful in all patients. The intrahepatic bile ducts were dilated in two patients (12%) and nondilated in 14 (88%). A right approach was used in nine patients (56%), a left approach was used in three patients (19%), and a bilateral approach was used in four patients (25%).
Complications subsequent to percutaneous transhepatic biliary drainage occurred in two patients (12%). One patient had a major episode of hemobilia secondary to arterial injury, with a false aneurysm of an intrahepatic artery that was successfully treated by means of selective embolization. The other patient, with severe acute necrotizing pancreatitis, developed a subcapsular hepatic hematoma. Surgical treatment of this hematoma was performed 15 days after drainage, but the patient died of recurrent bleeding. Two other patients died because of septic shock due to severe acute necrotizing pancreatitis with large pancreatic abscesses.
In 13 patients, biliary leak completely healed after drainage for 30–150 days (mean, 78 days), and nine patients (69%) had no residual stenosis (Figs 1, 2). In four patients (31%), cholangiography performed before withdrawal of the drainage catheter showed the bile duct to be narrowed at the site of the previous leak. This stenosis was treated by means of balloon dilation in two patients (Fig 3) and balloon dilation followed by insertion of a metallic stent (Cragg stent CS08-30, Min Tech, Obenburg, Germany; Gianturco-Z stent GZS-10-3.0-CF, Cook, Bloomington, Ind) in two patients. A patient with 30 days of drainage had a secondary biliary stenosis 12 months after the initial drainage procedure. In this patient, balloon dilation was performed successfully, and there was no recurrence of stenosis (follow-up, 40 months). All 13 patients remained cured (mean follow-up, 38 months; range, 11–76 months).
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Figure 1a. Biliary leak after cholecystectomy and choledochotomy in a 63-year-old man. (a) Percutaneous transhepatic cholangiogram shows extravasation of contrast medium (arrow) through a defect (arrowhead) in the common bile duct, without opacification of its distal part. (b) Percutaneous transhepatic cholangiogram obtained 18 weeks after biliary drainage with a 12-F catheter shows that the common bile duct (arrow) is normal. The patient remained cured 59 months after treatment.
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Figure 1b. Biliary leak after cholecystectomy and choledochotomy in a 63-year-old man. (a) Percutaneous transhepatic cholangiogram shows extravasation of contrast medium (arrow) through a defect (arrowhead) in the common bile duct, without opacification of its distal part. (b) Percutaneous transhepatic cholangiogram obtained 18 weeks after biliary drainage with a 12-F catheter shows that the common bile duct (arrow) is normal. The patient remained cured 59 months after treatment.
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Figure 2a. Biliary leak that complicated a laparoscopic cholecystectomy in a 40-year-old woman. (a) Percutaneous transhepatic cholangiogram shows extravasation of contrast medium (arrowhead) through a defect (small arrows) in the common hepatic duct and the biliary confluence. A large perihepatic biloma had been treated by means of percutaneous insertion of a vanSonnenberg 12-F catheter (large arrow) 7 days before the percutaneous transhepatic cholangiogram was obtained and biliary drainage was performed. (b) Percutaneous transhepatic cholangiogram obtained 3 weeks after biliary drainage with a 12-F catheter shows that biliary extravasation (arrow) persists. (c) Percutaneous transhepatic cholangiogram obtained 5 weeks after the image in b was obtained shows that the leak has healed. A residual narrowing of the central aspect of the left hepatic duct was considered not severe enough to require dilation. The patient remained cured 23 months after treatment.
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Figure 2b. Biliary leak that complicated a laparoscopic cholecystectomy in a 40-year-old woman. (a) Percutaneous transhepatic cholangiogram shows extravasation of contrast medium (arrowhead) through a defect (small arrows) in the common hepatic duct and the biliary confluence. A large perihepatic biloma had been treated by means of percutaneous insertion of a vanSonnenberg 12-F catheter (large arrow) 7 days before the percutaneous transhepatic cholangiogram was obtained and biliary drainage was performed. (b) Percutaneous transhepatic cholangiogram obtained 3 weeks after biliary drainage with a 12-F catheter shows that biliary extravasation (arrow) persists. (c) Percutaneous transhepatic cholangiogram obtained 5 weeks after the image in b was obtained shows that the leak has healed. A residual narrowing of the central aspect of the left hepatic duct was considered not severe enough to require dilation. The patient remained cured 23 months after treatment.
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Figure 2c. Biliary leak that complicated a laparoscopic cholecystectomy in a 40-year-old woman. (a) Percutaneous transhepatic cholangiogram shows extravasation of contrast medium (arrowhead) through a defect (small arrows) in the common hepatic duct and the biliary confluence. A large perihepatic biloma had been treated by means of percutaneous insertion of a vanSonnenberg 12-F catheter (large arrow) 7 days before the percutaneous transhepatic cholangiogram was obtained and biliary drainage was performed. (b) Percutaneous transhepatic cholangiogram obtained 3 weeks after biliary drainage with a 12-F catheter shows that biliary extravasation (arrow) persists. (c) Percutaneous transhepatic cholangiogram obtained 5 weeks after the image in b was obtained shows that the leak has healed. A residual narrowing of the central aspect of the left hepatic duct was considered not severe enough to require dilation. The patient remained cured 23 months after treatment.
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Figure 3a. Biliary leak that complicated a laparoscopic cholecystectomy in a 65-year-old woman. (a) Percutaneous transhepatic cholangiogram shows a defect (small arrows) in the confluence of the right and left hepatic ducts with extravasation of iodinated contrast medium along the surgical T tube (large arrow). The central right bile duct and the common hepatic duct adjacent to the bile leak are slightly narrowed. (b) Percutaneous transhepatic cholangiogram obtained 10 weeks after biliary drainage depicts narrowing of the central aspect of the right hepatic duct (small arrow) and of the upper part of the common hepatic duct (large arrow). Note the visibility of the cystic duct remnant overlying the common bile duct (arrowhead). (c) Percutaneous transhepatic cholangiogram obtained with the biliary catheter in place after balloon dilation shows that the stenosis is no longer present, and the catheter is removed. The patient remained cured 34 months after treatment.
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Figure 3b. Biliary leak that complicated a laparoscopic cholecystectomy in a 65-year-old woman. (a) Percutaneous transhepatic cholangiogram shows a defect (small arrows) in the confluence of the right and left hepatic ducts with extravasation of iodinated contrast medium along the surgical T tube (large arrow). The central right bile duct and the common hepatic duct adjacent to the bile leak are slightly narrowed. (b) Percutaneous transhepatic cholangiogram obtained 10 weeks after biliary drainage depicts narrowing of the central aspect of the right hepatic duct (small arrow) and of the upper part of the common hepatic duct (large arrow). Note the visibility of the cystic duct remnant overlying the common bile duct (arrowhead). (c) Percutaneous transhepatic cholangiogram obtained with the biliary catheter in place after balloon dilation shows that the stenosis is no longer present, and the catheter is removed. The patient remained cured 34 months after treatment.
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Figure 3c. Biliary leak that complicated a laparoscopic cholecystectomy in a 65-year-old woman. (a) Percutaneous transhepatic cholangiogram shows a defect (small arrows) in the confluence of the right and left hepatic ducts with extravasation of iodinated contrast medium along the surgical T tube (large arrow). The central right bile duct and the common hepatic duct adjacent to the bile leak are slightly narrowed. (b) Percutaneous transhepatic cholangiogram obtained 10 weeks after biliary drainage depicts narrowing of the central aspect of the right hepatic duct (small arrow) and of the upper part of the common hepatic duct (large arrow). Note the visibility of the cystic duct remnant overlying the common bile duct (arrowhead). (c) Percutaneous transhepatic cholangiogram obtained with the biliary catheter in place after balloon dilation shows that the stenosis is no longer present, and the catheter is removed. The patient remained cured 34 months after treatment.
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DISCUSSION
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The main causes of biliary leak are bile duct injury during laparoscopic cholecystectomy (10,11), hepaticojejunal anastomosis (8), common bile duct–to–common bile duct anastomosis associated with liver transplantation (3), and hepatic lobectomy (3,6). Biliary leaks due to severe acute necrotizing pancreatitis (4,5) and abdominal trauma (12–14) are less frequent.
Depending on the cause of the leak, early intervention is favored by many surgeons, and definitive surgical repair is attempted (1). Hepaticojejunal anastomosis is another procedure commonly used to treat biliary leaks. At a later stage of the disease, surgical reexploration is often difficult because of infection, edema, and scarring in the periportal area (4,6,11). Furthermore, when the leak involves the intrahepatic ducts, hepatic lobectomy is sometimes required (10).
Endoscopic drainage has been advocated widely as an alternative to surgery (2,3,12,13,15,16). ERCP depicts the extravasation together with the site and the size of the defect in the bile ducts. If there are bile leaks from the cystic duct or minor injury to the common bile duct wall, endoscopic sphincterectomy has been reported to be successful in 75% of patients (2). If there is a large biliary duct defect, it is necessary to decompress the biliary system by diverting bile flow from the defect. This can be done with endoscopic insertion of an endoprosthesis (2,3,13,15,17) or a nasobiliary tube (16).
When endoscopic insertion of a stent can be achieved, a definitive closure of the leak is attained with a frequency ranging from 75% (2) to 100% (13,15). However, the intubation of the common bile duct above the leak is sometimes difficult, and a technical failure rate of 46% has been reported (2). Furthermore, ERCP is not possible in patients with hepaticojejunal anastomosis.
Only a few patients have been reported on in whom percutaneous transhepatic biliary drainage has been used for biliary leak treatment (6–8). Kaufman et al (6) treated 12 patients with biliary leaks with percutaneous transhepatic biliary drainage: The biliary leak healed in six patients, while surgery was required in five patients. Percutaneous transhepatic biliary drainage was also successful in the three patients reported on by Vaccaro et al (8). Liguory et al (2) used percutaneous transhepatic biliary drainage in seven patients after failure of endoscopic biliary drainage and attained a closure of the leak in six patients.
Our results confirm the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks because 13 of 16 patients were completely cured. Leaks healed without any residual stenosis in most patients, while a slight bile duct narrowing at the site of the defect in the bile duct wall occurred in only five patients.
These results suggest that the use of a relatively large drainage catheter (12 F) and drainage for at least 7 or 8 weeks might prevent secondary stenosis of the bile duct after healing of the leak in most cases. However, a residual narrowing of the bile duct can be treated easily and successfully through the percutaneous route before withdrawal of the drainage catheter.
Postoperative biliary leaks are cured more easily by means of percutaneous transhepatic biliary drainage than are leaks due to severe acute necrotizing pancreatitis, in which the prognosis depends mainly on the severity of the pancreatic disease. In our series, 10 patients (100%) with a postoperative biliary leak recovered, while only three patients (50%) with severe acute necrotizing pancreatitis recovered. Two patients with severe acute necrotizing pancreatitis and large pancreatic abscesses died of septic shock unrelated to percutaneous transhepatic biliary drainage.
Surgical or endoscopic management of biliary leaks in patients with severe acute necrotizing pancreatitis is often difficult or unsuccessful. An endoscopic approach may be difficult or contraindicated because of ongoing severe acute necrotizing pancreatitis and deformity of the duodenum (4). These patients are usually clinically unstable and poor candidates for surgery. Therefore, percutaneous transhepatic biliary drainage can be a low-risk treatment option to avoid unnecessary surgery.
In patients with biliary leak, percutaneous transhepatic cholangiography and biliary drainage are sometimes technically difficult because the intrahepatic bile ducts are usually not dilated. As a result, the puncture site is more central than usual, and this may account for a higher risk of vascular complications than the risk in patients with dilated bile ducts; this is probably the main drawback of this therapeutic procedure. Vascular complications after percutaneous transhepatic biliary drainage have been reported in 7%–19% of patients (18,19) and usually are transient hemobilia (20). A subcapsular hematoma is usually a relatively benign complication of percutaneous transhepatic biliary drainage. However, a large subcapsular hematoma can be responsible for hepatic failure, as occurred in one patient in our series who died of recurrent bleeding after surgical drainage of the hematoma.
Arterial injury is relatively rare but is responsible for severe bleeding, with a frequency of 2% (18,20). This frequency is higher for benign biliary stenoses and leaks than for malignant lesions (20). Bleeding from an arterial injury can be controlled by performing arterial embolization (20). Cholangitis is another complication of percutaneous transhepatic biliary drainage that can be prevented with the administration of broad-spectrum antibiotics.
In conclusion, percutaneous transhepatic biliary drainage has proved to be an important technique in the management of biliary leak in patients in whom surgical and endoscopic treatments are impossible or unsuccessful. It may be the one procedure capable of healing the lesion in some patients. Although the puncture of nondilated intrahepatic bile ducts may be difficult, painful, and associated with a risk of vascular complications, percutaneous transhepatic biliary drainage can be an alternative to surgical management of biliary leaks, whatever their cause.
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Acknowledgments
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The authors thank John Hall, BA, for help in manuscript preparation and editorial assistance.
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Footnotes
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Abbreviation: ERCP = endoscopic retrograde cholangiopancreatography
Author contributions: Guarantor of integrity of entire study, C.L.; study concepts, O.E., C.L.; study design, D.M., G.S.; definition of intellectual content, O.E., C.L.; literature research, O.E., D.M.; clinical studies, O.E., G.S., D.M., O.D., C.L.; data acquisition, O.E., G.S., D.M., O.D., C.L.; data analysis, O.E., D.M., C.L.; manuscript preparation, O.E., D.M., C.L.; manuscript editing and review, O.E., C.L.
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References
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Abstract
Introduction
