Subscribe to RSS
DOI: 10.1055/s-0034-1365376
A minimally invasive technique utilizing percutaneous and endoscopic rendezvous for successful treatment of a proximal bile leak following partial hepatectomy
Corresponding author
Publication History
Publication Date:
22 April 2014 (online)
A 43-year-old woman presented with a grade B [1] bile leak after right hepatectomy for metastatic colon cancer. She developed subhepatic bilomas which were managed with percutaneous drains. Endoscopic retrograde cholangiography (ERC) demonstrated a high-grade bile leak secondary to a large defect in the left hepatic duct, possibly due to complete dehiscence of the staple line of the right hepatic bile duct. Despite placement of a fully covered self-expandable metallic stent (SEMS), the bile leak persisted. Percutaneous transhepatic biliary drainage (PTBD) was attempted. The left hepatic duct was accessed in an antegrade fashion; however, the guidewire repeatedly entered the subhepatic space and could not be directed into the common bile duct. Simultaneous ERC and PTBD were performed. The leak ([Fig. 1]) and discontinuity between the left hepatic duct and common bile duct was redemonstrated at ERC. A guidewire was advanced in a retrograde manner to the area just distal to the leak ([Fig. 2]). A 15-mm snare (Amplatz GooseNeck, Covidien, Plymouth, Minnesota, USA) was advanced in an antegrade manner across the left hepatic duct defect to capture the wire ([Fig. 3]) and pulled externally to secure biliary access. A percutaneous biliary drainage catheter was directed over the guidewire, through the SEMS, into the distal duodenum using endoscopic guidewire traction ([Fig. 4]). The drain was customized with additional side holes which remained within the intrahepatic biliary tree but not in the region of the ductal defect ([Fig. 5]). At 6-month follow-up, the subhepatic collections had resolved on imaging.
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1365376-i751cl1.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1365376-i751cl2.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1365376-i751cl3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1365376-i751cl4.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1365376-i751cl5.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Bile leaks occur in up to 10 % – 12 % [1] [2] of patients following hepatic surgery, and are a significant cause of postsurgical morbidity, prolonged hospital stay, and mortality [2]. Indications for resection of colorectal cancer liver metastasis have expanded in recent times, leading to larger and more complex resections [3]. Preoperative bevacizumab and surgical technique are independent predictors of bile leaks [2]. Establishing continuity between the biliary tree distal and proximal to the defect is crucial for successful treatment [4]. We describe successful establishment of biliary continuity using an ERC–PTBD rendezvous procedure (after failure of standard endoscopic techniques) to treat a large defect which obviated the need for repeat laparotomy.
Endoscopy_UCTN_Code_TTT_1AR_2AK
#
Competing interests: Payal Saxena has received consulting fees from Boston Scientific and research support from Cook Medical.
Mouen A. Khashab is a consultant for Boston Scientific and Olympus America and has received research support from Cook Medical.
Vikesh K. Singh is a consultant for Abbvie, Santarus, D-Pharm, and Boston Scientific.
All other authors have no relevant conflicts of interest to disclose.
-
References
- 1 Koch M, Garden OJ, Padbury R et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011; 149: 680-688
- 2 Guillaud A, Pery C, Campillo B et al. Incidence and predictive factors of clinically relevant bile leakage in the modern era of liver resections. HPB (Oxford) 2013; 15: 224-229
- 3 Mayo SC, Pulitano C, Marques H et al. Surgical management of patients with synchronous colorectal liver metastasis: a multicenter international analysis. Am Coll Surg 2013; 216: 707-716 discussion 716 – 708
- 4 Fiocca F, Salvatori FM, Fanelli F et al. Complete transection of the main bile duct: minimally invasive treatment with an endoscopic-radiologic rendezvous. Gastrointest Endosc 2011; 74: 1393-1398
Corresponding author
-
References
- 1 Koch M, Garden OJ, Padbury R et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011; 149: 680-688
- 2 Guillaud A, Pery C, Campillo B et al. Incidence and predictive factors of clinically relevant bile leakage in the modern era of liver resections. HPB (Oxford) 2013; 15: 224-229
- 3 Mayo SC, Pulitano C, Marques H et al. Surgical management of patients with synchronous colorectal liver metastasis: a multicenter international analysis. Am Coll Surg 2013; 216: 707-716 discussion 716 – 708
- 4 Fiocca F, Salvatori FM, Fanelli F et al. Complete transection of the main bile duct: minimally invasive treatment with an endoscopic-radiologic rendezvous. Gastrointest Endosc 2011; 74: 1393-1398
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1365376-i751cl1.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1365376-i751cl2.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1365376-i751cl3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1365376-i751cl4.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1365376-i751cl5.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)