Ethanol ablation for segmental bile duct leakage after hepatobiliary resection

doi:10.1067/msy.2002.118711

Surgery

Volume 131, Issue 1, January 2002, Pages 111-113

https://doi.org/10.1067/msy.2002.118711 Get rights and content

Abstract

Surgery 2002;131:111-3.

Section snippets

Case report

A 69-year-old woman was admitted to our hospital with advanced gallbladder carcinoma. On June 6, 2000, she underwent right hepatic lobectomy with en bloc resection of the caudate lobe and extra hepatic bile duct. Bilioenteric continuity was reestablished by left hepaticojejunostomy with a Roux-en-Y jejunal limb. On postoperative day 1, pure bile began to empty from the drain placed in the right subphrenic space and continued thereafter. Fistulography, performed on day 20, revealed leakage from

Discussion

This report shows that percutaneous ethanol ablation for a biliary fistula can be performed safely and effectively in humans. However, this technique is only applicable to fistulae that do not communicate with the remainder of the biliary tree (as in the present case), because seepage of absolute ethanol into the remainder of the biliary tree may not be retrievable and may cause irreparable damage. Ethanol injection completely eliminated biliary excretion from B2 without any serious adverse

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Endoscopic retrograde drainage is effective for managing bile leakage, which is relatively common after hepatectomy without bile duct reconstruction. However, the procedure is difficult to perform after pancreatoduodenectomy with choledochojejunostomy. We present a case of anterograde bile duct drainage for intractable bile leakage after hepatectomy in a patient with previous pancreatoduodenectomy.
An 80-year-old woman with a history of pancreatoduodenectomy for distal biliary cancer and adjuvant chemotherapy presented with bile leakage. Six years after the pancreatoduodenectomy, she underwent partial hepatectomy for suspected metastasis or intrahepatic cholangiocarcinoma. On the 9th postoperative day, bile leaked from her drainage tube forming an abscess cavity; this continued until the 28th postoperative day. We attempted selective anterograde drainage from the cut surface of the liver under fluoroscopic guidance using a guidewire and Cobra-type catheter. We selectively cannulated the entrance hole of the bile duct. Twenty days after the drainage, the abscess cavity disappeared. After 41 days, the tube was removed, and the patient was discharged. We suggest this procedure as a possible treatment option for difficult bile leakage cases.
A case of intractable bile leakage after hepatectomy in a patient with a previous history of pancreatoduodenectomy is difficult to manage, and usually needs surgical intervention. The effect of selective cannulation of the entrance hole of the bile duct has not been studied.
Selective anterograde bile duct drainage for intractable bile leakage after hepatectomy in a patient with a previous history of pancreatoduodenectomy successfully resolved bile duct leakage in our patient.
Ethylene-vinyl alcohol copolymer endobiliary obliteration of hepatic segmentsina patient with isolated bile leaks
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Citation Excerpt :
An isolated leak of 150–190 mL/d was successfully treated with segmental portal vein embolization (6). Ethanol sclerosis via the sinogram tract (1,11) or directly into isolated systems leaking approximately 50 mL/d (12) has also shown promising results. However, 6–23 sclerosing sessions are required (1,11).
A 54-year-old woman with a symptomatic giant hepatic hemangioma underwent an extended left hepatic trisegmentectomy complicated by 250–350 mL/d postoperative bilious drainage. After 5 months of therapy, drainage was unabated, and the patient was no longer a surgical candidate. Sinography revealed three distinct isolated bile duct leaks involving segments 6, 7, and 8. Endobiliary segmentectomy was achieved by obliterating the isolated systems with ethylene-vinyl alcohol copolymer (Onyx; ev3, Plymouth, Minnesota) during three fluoroscopic procedures. Bilious leaks were successfully eliminated, and compensatory hypertrophy of noninvolved liver occurred. At 2 years from the last embolization procedure, the patient remained asymptomatic with no bilious leak.
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Other methods for management of isolated draining intrahepatic bile ducts have been described previously. Percutaneous ethanol and acetic acid sclerotherapy has been used for isolated ducts in adult hepatectomy and adult donor-paediatric recipient LDLT.8,9,12-16 Limitations to this approach include loss of functional liver tissue, prolonged treatment course (frequently more than 4–6 ablations) requiring multiple sessions of anaesthesia and radiation exposure.8,9,12,14
A strategy to increase the number of size- and weight-appropriate organs and decrease the paediatric waiting list mortality is wider application of sectional orthotopic liver transplantation (OLT). These technical variants consist of living donor, deceased donor reduced and split allografts. However, these grafts have an increased risk of biliary complications. An unusual and complex biliary complication which can lead to graft loss is inadvertent exclusion of a major segmental bile duct. We present four cases and describe an algorithm to correct these complications.
A retrospective review of the paediatric orthotopic liver transplantation database (2000–2010) at Washington University in St. Louis/St. Louis Children's Hospital was conducted.
Sixty-eight patients (55%) received technical variant allografts. Four complications of excluded segmental bile ducts were identified. Percutaneous cholangiography provided diagnostic confirmation and stabilization with external biliary drainage. All patients required interval surgical revision of their hepaticojejunostomy for definitive drainage. Indwelling biliary stents aided intra-operative localization of the excluded ducts. All allografts were salvaged.
Aggressive diagnosis, percutaneous decompression and interval revision hepaticojejunostomy are the main tenets of management of an excluded bile duct. Careful revision hepaticojejunostomy over a percutaneous biliary stent can result in restoration of biliary continuity and allograft survival.
Trisectionectomy
2009, Surgical Pitfalls
Management of excluded segmental bile duct leakage following liver resection
2009, HPB
Postoperative bile leak secondary to a fistula is a known complication of hepatic surgery. Four different biliary fistula sub-types have been described: type A refers to minor leakage from the bile duct stump; type B to major leakage caused by insufficient closure of the bile duct stump; type C to major leakage caused by injury to the bile duct, and type D (the rarest) to the division and exclusion of a bile duct. This complication results from functional liver parenchyma in which bile drainage is excluded from the main duct.
A retrospective review of the database for 163 patients diagnosed with post-hepatic surgery bile leak from April 1992 to June 2007 was performed.
Three patients were found to have type D biliary fistula, with durations of 3–21 months. The bile leak developed after a right hepatectomy in two patients and a right hepatectomy extending to segment IV in one patient. All three patients were rescheduled for surgical exploration, following failure of medical treatment. The procedure consisted of repeat resection of the independent liver parenchyma containing the fistula. One patient developed a postoperative leak from a hepaticojejunal anastomosis (treated conservatively) and the other two patients had an uneventful recovery. No recurrence of bile leak was encountered during their follow-up.
Our experience indicates that conservative treatment is deceptive and not efficacious. For this condition, surgical intervention is the treatment of choice because it is very effective and is associated with a low morbidity.
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^*: Reprint requests: Takanori Kyokane, MD, First Department of Surgery, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.

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Case ReportEthanol ablation for segmental bile duct leakage after hepatobiliary resection*

Abstract

Section snippets

Case report

Discussion

J Surg Res

J Vasc Interv Radiol

Surgery

Ablation of renal tumors with absolute ethanol: a new technique

Radiology

Case Report
Ethanol ablation for segmental bile duct leakage after hepatobiliary resection*