Percutaneous Therapy for Anastomotic Bile Leak in Liver-Transplant Patients with Nondilated Bile Ducts

Abstract

Bile leaks remain a significant cause of postoperativemorbidity in 4.9% to 26.6% of liver transplant recipients[1–4] and can be managed surgically or nonsurgically.Most leaks can be treated with interventional radiologictechniques. However, in cases with bile ducts that aredecompressed because of massive leakage (mostly anas-tomotic), percutaneous access into a peripheral bile duct isusually difficult. In the cases presented here, we performedretrograde catheterization of a peripheral bile duct to makethe percutaneous procedure easier to perform and lesstraumatic for the patient.Case ReportsCase 1Forty-nine days after orthotopic liver transplantation, a 59-year-oldman presented withabdominalpainandtenderness.A large perihepatic fluid collection, or biloma, was found onultrasound examination. After bile-stained fluid aspiration,percutaneous drainage of the perihepatic biloma was per-formed under ultrasonographic guidance. Following thisprocedure, output through the drainage catheter was high(>200 ml per 24 h). Two weeks later, drip-infusion pouch-ography obtained via the drainage catheter showed a com-munication between the biloma and the biliary system at thesite of the surgical anastomosis. Endoscopic managementwas our first treatment option, but it failed in crossing theanastomosis. We decided to perform percutaneous transhe-patic biliary drainage. Because the leak had caused decom-pressionofbileducts,wedecidedtouseourbilomaaccesstomake the percutaneous bile duct puncture easier.The procedure was performed after antibiotic prophy-laxis. After initiation of intravenous (IV) sedation and localanesthesia, the drainage catheter was exchanged for a 6-Fintroducer sheath (Arrow International, Inc., Reading, PA,USA) positioned over a guide wire. A 5-F catheter (SOSOMNI; AngioDynamics, Queensbury, NY, USA) was in-serted from the biloma pouch and passed through the dis-rupted anastomosis. Then a microcatheter (fast tracker;Boston Scientific, Natick, MA, USA) was coaxially in-serted into a peripheral bile duct available for percutaneousaccess (Fig. 1), and contrast material was injected throughthe microcatheter to opacify and distend this duct. Underfluoroscopy and using a 21-gauge needle (AccuStickIntroducer System; Boston Scientific), a percutaneouspuncture was made in the same duct.After the percutaneous needle puncture was made in theduct, a coaxial dilator (AccuStick Introducer System;Boston Scientific) was placed over an 0.018-in. Nitinolguide wire, then a 0.035-in. glide wire (Terumo, Tokyo)was advanced through the dilator, and a 6-F introducer(Terumo) was inserted into the duct over the wire. A 5-Fcatheter (Terumo) with a guide wire was used to cross theleak site. Then, over a stiff guide wire (Amplatz Super StiffGuide Wire; Boston Scientific), a 10-F biliary drainagecatheter (Flexima; Boston Scientific) with multiple sideholes positioned on both sides of the anastomosis wasplaced to divert bile away from the defect. The leak haddisappeared after 57 days of percutaneous biliary drainage.