Minimally Invasive Treatment of High Output Isolated Biliary Fistula after Hepato-Biliary Surgery

Abstract

Introduction: Post-hepatectomy leakage from major bile ducts, excluded from the rest of the biliary tree, will result in high output biliary fistulas, with no chance of spontaneous healing. Radical treatment of this condition includes liver resection and/or bilio-enteric anastomosis, with high risk of complications. Minimally invasive procedures such as bile duct ablation (BDA) and percutaneous transhepatic portal vein embolization (PTPE) have been reported in case reports with mixed outcome. We decided to test a combination of PTPE and BDA for treatment of High Output Isolated Biliary Fistulas (HOIBF). Method: HOIBF is diagnosed by Primovist® enhanced MRI. After identifying the leaking bile duct the following procedure is initiated: • Percutaneous placement of a catheter in the leaking bile duct • Selective PTPE in the corresponding segmental portal vein • No earlier than 2 weeks later ablation is performed, using 3-5 cc of pure alcohol, instilled in the excluded bile duct. The alcohol is aspirated 5 minutes later • Repetition of the ablation procedure every 3rd day, until fistula output is < 25 cc/24 hours and/or bilirubin concentration of the drain fluid is < 50 μmol/l • The biliary catheter is removed Results: From July 2019 to March 2021 four patients with HOIBF were treated with this new procedure. Details of the location, output and treatment of the HOIBF appear from Table 1. All fistulas were closed successfully without complications. No recurrence occurred in the 3-16 month observation period. Conclusion: Radical treatment of HOIBF with staged combination of PTPE and BDA seems to be efficient and safe.