Interventional radiology in the management of benign biliary stenoses, biliary leaks and fistulas: a pictorial review

Abstract

Background: Benign biliary postoperative stenoses and biliary leaks and fistulas usually occur due to injury after laparoscopic cholecystectomy, gastric or hepatic resection, bilio-enteric anastomoses and after liver transplantation. In most of the cases a new surgical intervention is not possible and the percutaneous trans-hepatic approach is of paramount importance in the diagnosis and treatment of the problem. This review aims to highlight the spectrum of percutaneous cholangiographic findings and methods of treatment of postoperative benign biliary stenoses and biliary leaks and fistulas. In the case of stenosis, dilation of the narrow tract is the usually the first approach, whereas in the case of leaks and fistulas bile diversion with drainage is usually attempted in order to seal the fistulous tract. However, a great variety of combination of materials and techniques may be used on a "case-by case" approach

Methods: A selection of cases of benign biliary postoperative stenoses and biliary leaks and fistulas that were managed percutaneously are presented and the most common lines of approach are discussed.

Conclusion: The imaging spectrum of percutaneous treatment of benign biliary postoperative stenoses and biliary leaks and fistulas is presented in order to aid interpretation and management with image guided procedures. TEACHING POINTS : • Treatment of benign biliary stenosis is performed with cholangioplasty and stents. • The main goal of fistula treatment is to divert the bile away from the site of bile wall defect. • Drain collection and tract embolisation are the other options for bile leak percutaneous treatment.

Fig. 1

a Cholangiogram through a T-tube that shows the presence of a bile leak due to traumatic rupture of the main bile duct (small arrow). b The T-tube was exchanged to a locking pigtail drain catheter that drained externally. Cholangiographic control revealed that the leak was sealed a couple of weeks later

Fig. 2

a Biliorrhea post open cholecystectomy occurred and ERCP failed to access the biliary tree due to concomitant stenosis of the common bile duct (CBD). Percutaneous puncture of the right side bile ducts and contrast injection. Cholangiogram revealed leakage from the ducts of Luscka (black arrow) and severe obstruction of the CBD. b The CBD was catheterised and a self-expandable metallic stent was deployed in order to drain the bile away from the side of leak

Fig. 3

a Laceration and obstruction of common hepatic duct post laparoscopic cholecystectomy that led to biloma formation. b Percutaneous CT-guided drainage of the biloma. c Cholangiographic picture that confirms the communication of the collection with the biliary system. Surgical repair of the bile ducts followed

Fig. 4

a Fistula between the bile ducts and a hepatic vein was revealed after a percutaneous biliary procedure (black arrow). b The fistulous tract was embolised with a pellet of Gelfoam (black arrow)

Fig. 5

A patient with intra-hepatic stenosis and bile leak post biliodigestive anastomosis. a Percutaneous access that revealed the stenotic area (arrow). b Dilation of the stenotic tract. c The patient returned 9 years later with a new leak that was initially embolised with coils (black arrow) and then (d) a covered stent was deployed to seal the leak

Fig. 6

Complete avulsion of the bile ducts post cholecystectomy, with the presence of a bile leak outside the biliary tree. a Cholangiogram that reveals the area of bile leakage (white arrow). b A “rendezvous” procedure was performed with percutaneous and endoscopic access, and (c, d) restored the connection of the bile ducts with the duodenum