Embolization of extrahepatic biliary leakage using NBCA

Abstract

Biliary fistula and bile leakage are complications that can occur during hepato-biliary or intestinal surgery and percutaneous biliary intervention. In some cases, spontaneous resolution is possible but more often re-intervention (surgical or percutaneous) is necessary. We present the case of a 45 y-o male patient who underwent duodenocefalopanreasectomy (Whipple procedure) with bilio-digestive anastomosis for adenoma of the duodenal papilla of Vater, complicated by the formation of a fistula through the bilio-digestive anastomosis. Conservative treatment with percutaneous biliary drainage was attempted in order to promote spontaneous resolution of the fistula. The persistence of the fistula brought the patient to treatment through interventional techniques. Sealing of the bilio-peritoneal fistula was obtained using N-butil-Cyanoacrylate .

Keywords: Biliary drainage; Biliary leakage; N-butyl cyanoacrylate; Percutaneous embolization; Transhepatic embolization.

Fig. 1

Axial (A) and coronal (B) MR TSE T2 images (MR performed before surgery); Images show slightly hyperintense ampullar mass protruding inside the lumen (black arrow in “a”), which determined intermittent jaundice and abdominal pain. Coronal view shows the mass bulging inside duodenal lumen (black arrowhead in “b”).

Fig. 2

CT scan performed 3 days after surgery (axial late arterial phase image). In the place of the bilio-digestive anastomosis a fluid collection developing towards mid line, anteriorly to the pancreaticojejunostomy is visible with free peritoneal air bubbles (white arrowhead); effusion and peritoneal fat stranding in the subhepatic region is also seen; free peritoneal fluid in parieto-colic groove, perisplenic space and anteriorly to retroperitoneum is not related to anastomotic dehiscence.

Fig. 3

(A) Cholangiography performed on fourth day after surgery. Preliminary cholangiogram shows presence of biliary leakage (white arrowhead). From this projection the percutaneous drainage (white arrow) and the Chiba's needle (black arrowhead) are overlapping. (B) final X-ray acquisition shows the final result of the biliary drainage, with the tip positioned through the anastomosis in the jejunal loop.

Fig. 4

Cholangiography performed ten days after biliary drainage positioning. Dehiscence was still remarkable (white arrowhead).

Fig. 5

Procedure of biliary fistula sealing performed after biliary drainage revision on tenth day. (A) Fluoroscopy image after administration of mixture of Lipiodol and NBCA (1:1). Without DSA acquisition, image shows the mixture as a radiopaque cast of the fistula. (B) DSA acquisition with contrast medium shows complete obliteration of the fistulous tract.