Percutaneous neo-anastomosis creation of two excluded accessory bile ducts to Roux-en-Y hepaticojejunostomy after choledochocele resection

INTRODUCTION

Post-surgical bile leaks can result from a variety of hepatobiliary surgeries, including partial hepatectomy, liver transplantation, and cholecystectomy. The incidence of post-surgical bile leaks has been reported to be as high as 2% in cholecystectomy, 10% in partial hepatectomy, and 25% in liver transplantation.^[1-4] The high rate of biliary complications likely reflects the sensitive nature of biliary epithelium to ischemic insults in comparison to hepatocytes and vascular epithelium. If untreated, a combination of bile, blood products, and devitalized organs presents an ideal environment for bacterial growth and can result in intraperitoneal septic complications, frequently results in liver failure and poor prognosis.^[5]

Nagano et al. classified post-operative bile leak into four types, with type D leakage described as leakage from isolated bile duct(s).^[6] Most type A-C bile leaks can be managed by percutaneous drainage. However, an isolated ductal leak (type D) may not respond to a drainage procedure alone and requires an additional invasive procedure to divert bile internally. Here, we aim to present a case of percutaneous biliary neo-anastomosis creation after Roux-en-Y hepaticojejunostomy complicated by an infected biloma from isolated hepatic ducts. Ultimately, the bilio-enteric neo-anastomosis was proven to be patent, and the drain was removed successfully.

CASE REPORT

A 19-year-old male with a history of choledochal cyst status post-excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy, complicated by an infected biloma status post-percutaneous drain placement. During the drain study, there was a persistent bile leak and was clear that there were isolated inferior-lateral and superior-medial ductal systems [Figure 1]. He presented to our department for multi-stage biliary diversion.

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Figure 1:

19-year-old male with post-operative biloma: Percutaneous drainage phase. (A and B) Fluoroscopic drain study and intraoperative computed tomography of the right upper quadrant showed small isolated hepatic ducts (*) draining into the biloma.

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The initial goal was to achieve internal biloma drain into the Roux limb. The Roux limb was punctured, and a wire was passed into the Roux limb. Next, the existing abscess drain was exchanged for a gastric cannula. Using the wire as the target, the Roux limb was punctured from the biloma side with a 21G needle through the gastric cannula [Figure 2A]. Finally, a drain was placed through the biloma and into the Roux limb, achieving internal biloma drainage [Figure 2B].

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Figure 2:

19-year-old male with post-operative biloma: Initial biloma drainage internalization. (A) A target wire (*) was placed percutaneously into the Roux limb under ultrasound guidance and confirmed on computed tomography (CT). The gastric cannula was positioned within the biloma cavity and directed toward to the target wire under fluoroscopy. The Roux limb was punctured with a 21 G needle (arrow) advanced through the gastric cannula and a wire was advanced into the Roux limb. The position was confirmed on CT. (B) Completion image of the first stage internalization procedure. Note the drain now traversed the biloma (*) and terminates in the Roux limb. A few isolated ducts were seen. These were targeted in the subsequent interventions.

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The patient was brought back for internalization of isolated latero-superior right hepatic ducts. The central aspect of the isolated hepatic ductal system (adjacent to anastomosis) was accessed under fluoroscopy and a wire was advanced through the central duct, the biloma cavity, the bilio-enteric fistula, and through the existing drain tract to achieve body floss access [Figure 3A]. Next, a directional catheter was advanced from the drain tract retrograde and parallel to the body floss wire, into a more peripheral branch. A snare was advanced through the catheterto serve as a target. The peripheral duct was then punctured under fluoroscopy and a wire was snared from the right lateral access to achieve body floss access [Figure 3B]. From the same right lateral access, a combination of wire and catheter was used to cannulate the Roux limb through the existing tract between biloma and Roux limb [Figure 4]. Finally, a biliary drain was placed from the isolated right hepatic duct, through the biloma, and into the Roux limb. A safety drain was placed in the existing drain tract [Figure 5].

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Figure 3:

19-year-old male with post-operative biloma: Internalization of laterio-inferior right hepatic duct. (A) An occlusion balloon was advanced over the wire into the Roux limb through the existing drain tract (thick white arrow). The balloon was inflated to occlude enteric outflow and cholangiogram was performed. A faint outline of the intrahepatic ducts can be seen (*). After the duct was opacified, a 21 gauge needle (thin black arrow) was used to puncture the central biliary tree and a wire was passed out of the tract into the abscess cavity to help identify the origin of the duct from the cavity since it could not be engaged primarily. Using this wire as a guide to the orgin of the duct, a directional catheter was sent retrograde into the peripheral duct. A snare was advanced into a peripheral duct (skinny white arrow). (B) Using the snare (*) as a target, the peripheral duct was punctured under fluoroscopy and a wire was snared through to the abcess cavity in preparation to get it into the roux limb.

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Figure 4:

19-year-old male with post-operative biloma: Internalization of laterio-inferior right hepatic duct, continued. (A) A combination of reverse curve catheter and wire was used to direct the wire into the Roux limb through the established tract (neo-anastomosis) between the biloma and the Roux limb. Balloon angioplasty (*) of the tract was performed to facilitate drain placement. (B) Wire-o-gram of multiple safety wires. Dashed line represented the safety wire from the right lateral access for body floss access. The dotted line represented working wire, over which the occlusion balloon was advanced into the Roux limb. The unmarked line represented working wire advanced from the right lateral access into the Roux limb and looped within the Roux limb.

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Figure 5:

19-year-old male with post-operative biloma: Internalization of laterio-inferior right hepatic duct, continued. (A) The reverse curve catheter was advanced deep into the Roux limb. Note the course of the catheter, which entered a peripheral duct, traversing the biloma, and into the Roux limb, creating a tract of neo-anastomosis. (B) Completion image demonstrating the new right-sided biliary drain and a safety drain (*) left in the existing drain tract.

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The patient was then brought back to internalize the isolated medio-superior hepatic ducts. Through the left-sided drain tract, the duct was catheterized in a retrograde fashion [Figure 6A]. A snare was placed into the peripheral duct as a target and a needle was advanced into the bile duct under fluoroscopy [Figure 6B]. A biliary drain was placed to achieve internalization of all isolated ducts.

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Figure 6:

19-year-old male with post-operative biloma: Internalization of medio-superior hepatic duct. (A) A directional catheter was advanced through the existing drain tract retrograde into the isolated duct and a snare was placed to serve as the target. A 21 G needle was advanced into the duct (*) under fluoroscopy guidance. A wire was advanced through the needle and snared across to achieve body floss access. (B) Similar to prior internalization, a combination of reverse curve catheter and wire was used to cannulate the Roux limb through the existing tract between the biloma and the Roux limb, like before. Note the course of the catheter, which entered a peripheral branch of the medio-superior duct, traversing the biloma and terminating in the Roux limb (thick white arrow). Safety wire (*) was seen for body-floss access. The prior latero-inferior drain was replaced with a placeholder angle tip catheter (thin white arrow).

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The multi-stage internalization spanned over a period of 2 months. The patient tolerated all procedures well except for a subcapsular biloma 2 weeks after the latest drain placement, which was suspected to be secondary to bile leakage along the course of the drain. This was drained without any issue. During the most recent drain check, an over-the-wire cholangiogram demonstrated widely patent neo-anastomoses and no bile leakage [Figure 7]. The tube was removed.

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Figure 7:

19-year-old male with post-operative biloma: Final internalization of both isolated hepatic ducts. (A) Final internalization image showed both drains in good position. (B) Over-the-wire cholangiogram showed widely patent neo-anastomoses into the Roux limb (*). No evidence of residual biloma.

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DISCUSSION

Bile leak is one of the common complications after hepatobiliary surgery. However, isolated bile ductal leak (type D) is rare, with a reported incidence rate of 0.2%.^[7] Surgical interventions may allow for identification and repair of the leakage site, but are often complicated by dense adhesions that render dissection and repair higher risk.^[8] Non-surgical interventions, such as endoscopic drainage procedures, have been described in the literature. Endoscopic ultrasound-guided biliary drainage utilizes various intrahepatic or extrahepatic access sites to the biliary system to achieve internal drainage with high technical and clinical success rates.^[9] However, due to the tortuosity following Roux-en-Y anastomosis, reaching the bilio-enteric anastomosis is not always feasible endoscopically.

Therefore, percutaneous treatment by interventional radiologists is a well-described and well-established option for this patient cohort, particularly in the setting of post-surgical stenosis and minor leak.^[10] However, in patients such as ours, where isolated ducts are present, percutaneous external drainage without internalization can result in “tube-for-life,” which significantly hampers patients’ quality of life. In this setting, biliary neo-anastomosis creation can achieve internal drainage of the isolated bile ducts, and various techniques have been reported in the literature. In a recent case series, Habibollahi et al. described sharp needle recanalization of the isolated hepatic duct to achieve bilio-biliary, bilio-gastric, and bilio-jejunal neo-anastomosis with a high clinical success rate.^[11] Recanalization could be performed using a long 21-G needle through a Cope gastric cannula (Cook Medical, Bloomington, IN) or Rosch-Uchida transjugular liver access set (Cook Medical, Bloomington, IN) from the isolated bile duct into the targeted biliary or enteric lumen. Alternatively, Mansueto et al. have described a retrograde sharp needle recanalization technique, where enteric access was obtained initially. Rosch-Uchida transjugular liver access set (Cook Medical, Bloomington, IN) was advanced through the enteric access and into the opacified bile duct to achieve bilio-enteric neo-anastomosis. The clinical success rate was 100% without major complications.^[12] Similar case reports/series using needle sharp recanalization have been reported in the literature with high success rates.^[13-17] In addition, alternative sharp recanalization techniques have been described, including a recent case series by Nakhostin et al. detailing biliary-enteric neo-anastomosis using either the backend of a stiff guidewire or dedicated re-entry device (Outback® Elite Re-entry catheter (Cordis, Miami Lakes FL, USA)).^[18] Clinical successes were achieved in all patients. Furthermore, Robins et al. described using radiofrequency wire (PowerWire; Baylis Medical; Toronto; ON) to achieve percutaneous bilio-enteric neo-anastomoses in five patients with no reported complications.^[19]

Our patient was particularly challenging given that he had multiple isolated hepatic ducts draining into an infected biloma, which required dedicated management initially to achieve internal biloma drainage. Our case and prior series have demonstrated that biliary neo-anastomosis is technically feasible and safe when undertaken in a stepwise fashion without the need for the patient to return to the operating room.

CONCLUSION

Post-surgical bile leak is not an infrequent complication of hepatobiliary surgery. In certain patients, simple drainage procedure is not sufficient to manage a major ductal leak. Our case has demonstrated the utility of step-wise percutaneous biliary neo-anastomosis creation in managing multiple isolated ductal leaks in a young patient.