Management of Biliary Leaks

General Clinical Considerations and Indications for Percutaneous Treatment

• Major biliary leakage is unlikely to resolve spontaneously (i.e., there is ongoing abdominal drainage of a significant amount of bilious fluid).

• Surgical therapy is often not necessary. (Definitive healing of the leakage site is generally expected after endoluminal decompression alone.)

• Surgical therapy is contraindicated because of extensive tissue adhesions (e.g., previous operations).

• Poor patient condition, with high risk for anesthesia.

• Endoscopic management not possible because of:

  • Enteric Roux-en-Y anastomosis

  • Recent duodenotomy (air insufflation can cause a rupture at the anastomosis [e.g., at the suture line])

  • Inability to probe the duodenal papilla or the common bile duct

  • Inability to negotiate a biliary stricture retrograde

In patients with massive biliary peritonitis, surgical revision and peritoneal lavage are usually necessary. Bile duct transection or disruption requires surgical therapy as well. In contrast to the blind-ending ducts of Luschka, the cystohepatic ducts drain liver parenchyma. Thus injuries to the cystohepatic ducts must be treated by either surgical biliary reconstruction or diversion to the jejunum.

If surgical treatment is not necessary or is impossible, endoluminal biliary drainage is indicated for persistent biliary leakage. The principle of healing a bile leak is to create a low-pressure system along the biliary tract by means of internal or external drainage. Endoscopic therapy with nasobiliary drainage, sphincterotomy, or placement of an endoprosthesis has been reported to result in a high closure rate of up to 82%. Because percutaneous transhepatic access is more invasive, endoscopic retrograde cholangiopancreatography is recommended as the first option. However, when the duodenum or the common bile duct cannot be cannulated, percutaneous transhepatic biliary drainage (PTBD) is the only endoluminal treatment option. PTBD serves to decompress the biliary system and redirect bile flow from the defect into the bile ducts. This percutaneous intervention alone may lead to sufficient healing of the leakage site such that additional surgery is not necessary (see Fig. 94.1 ). In critically ill patients, PTBD may allow the patient’s condition to improve before subsequent definitive surgery ( Fig. 94.2 ).

Contraindications

• Coagulopathy that cannot be corrected. Because the risk of uncontrollable hemorrhage from the liver is high in patients with coagulopathy, every effort should be made to correct or improve coagulation status before the procedure.

• History of allergies to contrast material. During hepatic puncture for PTBD, contrast material is likely to be injected into blood vessels before a bile duct is opacified. If a patient is known to be allergic to contrast agents, cortisone and antihistamine should be administered to the patient prophylactically.

Equipment

A modern C-arm unit with pulsed fluoroscopy is desirable because fluoroscopy times can be lengthy when attempting to percutaneously puncture nondilated bile ducts. Apart from the anesthesiology equipment, in our unit the following material is available to the interventionist:

• • 5- and 10-mL syringes

  • Sterile swabs

  • Nonionic water-soluble contrast agent (300–370 mg iodine/mL)

  • Local anesthetic: 5 to 10 mL of 2% lidocaine and injection needles

  • Single-puncture technique: Neff Percutaneous Access Set (William Cook Europe, Bjaeverskov, Denmark):

    • Small-gauge stainless steel access needle with an inner stylet

    • 0.018-inch guidewire

    • Coaxial introducer system consisting of three parts: an outer sheath, an inner tapered introducer, and an innermost metal stiffening cannula

  • 0.035-inch hydrophilic Radiofocus guidewire M (Terumo Medical Corp., Tokyo, Japan)

  • 5F Angled Taper Glidecath (Terumo)

  • 0.035-inch Amplatz Extra Stiff guidewire (William Cook Europe)

  • 8.3F ring, Lunderquist biliary drainage catheter (or an equivalent catheter)

  • 3-0 cutaneous suture

  • 10F and 12F Munich drainage catheters (Peter Pflugbeil GmbH, Zorneding, Germany): perforated bile duct drainage with a special flange (perforation distance, 7.5, 10, or 15 cm), connecting tube, sealing cap, and adapter (or equivalent catheters)

  • Bandage material