Percutaneous Management of Postoperative Bile Leaks with an Ethylene Vinyl Alcohol Copolymer (Onyx)

Abstract

Purpose: The management of postoperative bile leakage is challenging especially if the leak rises from the cut surface of the liver and endoscopic treatment fails. Percutaneous transhepatic treatment of bile leaks with biliary drainage is accepted but often requires long-term placement of the drains and is associated with treatment failures. This series evaluates selective embolization of bile ducts with an ethylene vinyl alcohol copolymer (Onyx) in patients with postoperative bile leaks as an alternative treatment option.

Materials and Methods: Between January and September 2012, five consecutive patients with persistent postoperative bile leaks underwent percutaneous transhepatic Onyx application and were analyzed regarding procedural management, complications and success rates.

Results: The persistent bile leaks were situated at the cystic stump (after cholecystectomy, n = 2), at the cut surface of the liver (after extended liver resection, n = 2) and at the surface of the liver after surgical exploration and perihepatic abscess (n = 1). Bile drainage alone (endoscopic or percutaneous) failed in all patients and open redo-surgery was deemed potentially harmful. Bilomas were externally drained in all patients before Onyx application. For the closure of bile leaks, Onyx was injected through a microcatheter in a previously built coil nest to keep Onyx in place. All bile leaks were initially closed immediately. In the 2nd week after Onyx embolization, 2 patients showed recurrent small bile leaks without clinical symptoms. In the 4th week after Onyx application, all leaks were closed. No complications occurred.

Conclusion: All leaking bile ducts were initially closed immediately after Onyx application. In the 2nd week after Onyx application, 2 patients showed small bile leaks without clinical symptoms. All leaks were closed in the 4th week after Onyx application. Key Points: Percutaneous treatment of postoperative bile leaks with Onyx seems to be an effective therapy if endoscopy fails and redo-surgery is deemed harmful.

Citation Format:

• Uller W, Müller-Wille R, Loss M et al. Percutaneous Management of Postoperative Bile Leaks with an Ethylene Vinyl Alcohol Copolymer (Onyx). Fortschr Röntgenstr 2013; 185: 1182 – 1187

Zusammenfassung

Ziel: Die Therapie postoperativer Galleleckagen ist sehr anspruchsvoll, insbesondere wenn sich das Galleleck an der Resektionsfläche der Leber befindet und eine endoskopische Therapie nicht erfolgreich ist. Eine perkutane Behandlung ist möglich, aber meist mit langen Drainagenverweildauern und Therapieversagen vergesellschaftet. Diese Studie evaluiert den selektiven Verschluss von Gallengängen mit einem Ethylen-Vinylalkohol-Kopolymer (Onyx) als Therapieoption bei Patienten mit postoperativem Galleleck.

Material und Methoden: Zwischen Januar und September 2012 wurde bei 5 konsekutiven Patienten mit persistierenden postoperativen Galleleckagen perkutan transhepatisch Onyx appliziert. Das prozedurale Vorgehen, Komplikationen sowie technischer Erfolg wurden evaluiert.

Ergebnisse: Die persistierenden Galleleckagen befanden sich an der Absetzung des Ductus cysticus nach Cholezystektomie (n = 2), an der Resektionsfläche (nach erweiterter Leberresektion n = 2) und an der Leberoberfläche nach chirurgischer Exploration und perihepatischem Abszess (n = 1). Die Therapie mit alleiniger Drainage der Galleflüssigkeit (endoskopisch oder perkutan) versagte bei allen Patienten und erneute offene chirurgische Revisionen wurden als zu invasiv gewertet. Die Biliome wurden bei allen Patienten vor Onyxapplikation nach extern drainiert. Zum Verschluss des Gallelecks wurde Onyx durch einen Mikrokatheter in ein zuvor platziertes Coilnest appliziert um eine Dislokation des Onyxs mechanisch zu verhindern. Alle Galleleckagen waren initial sofort verschlossen. In der 2. Woche nach Onyxverschluss zeigten 2 Patienten ein wiederauftretendes, kleines, klinisch asymptomatisches Galleleck. In der 4. Woche nach Onyxapplikation waren alle Leckagen verschlossen. Es traten keine Komplikationen auf.

Schlussfolgerung: Nach Onyxapplikation waren alle Galleleckagen sofort verschlossen. In der 2. Woche nach Onyx zeigten 2 Patienten ein kleines asymptomatisches Leck, welches in der 4. Woche nach Onyxapplikation komplett verschlossen war. Kernaussagen: Die perkutane Behandlung postoperativer Galleleckagen mit Onyx scheint eine effektive Therapie zu sein, wenn eine endoskopische Therapie scheitert und erneute operative Revisionen zu invasiv sind.

Key words

bile ducts - interventional procedures - percutaneous - PTC - PTBD - biliary leakage

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