Portobiliary Fistula Research Articles

Management of a Portobiliary Fistula and Obstructive Biliopathy in a Split Liver Graft Transplant Recipient Posthepaticojejunostomy with Portal Stent Graft

AbstractBiliary complications following liver transplantations, in the form of bile leak and bile duct strictures, are well recognized. Portobiliary fistulas in the transplant setting are rare, but may cause potentially life-threatening complications. The presented case shows the successful treatment of a hilar portobiliary fistula in a transplanted liver posthepaticojejunostomy with portal vein stent graft followed by biliary drainage with percutaneous hepaticojejunostomy stricture dilatation.

S3747 Recurrent Ascending Cholangitis and Polymicrobial Hepatic Abscesses in a Patient With Porto-Biliary Fistula After Liver Transplantation

S3747 Recurrent Ascending Cholangitis and Polymicrobial Hepatic Abscesses in a Patient With Porto-Biliary Fistula After Liver Transplantation

Safety and Effectiveness of a Novel Tips Access Set with Steerable Cannula in a Swine Model

PurposeThis study aimed to assess the safety, effectiveness, and feasibility of the Liverty™ transjugular intrahepatic portosystemic shunt (TIPS) access set, which has an ergonomic handle that allows for in situ cannula tip deflection and a distal steerable cannula angle, versus the COOK® Rosch-Uchida Transjugular Liver Access Set (RUPS-100) in healthy pigs.MethodsTwelve pigs randomly underwent TIPS with the Liverty™ set or the RUPS-100 set. Three interventionalists performed 4 TIPS procedures, 2 with each set. The primary outcome was procedural success, defined as successful establishment of the intrahepatic portosystemic shunt and stent placement.ResultsThe shunt was successfully established in 11 pigs. The procedural success was achieved in all 6 pigs in the Liverty™ group and 5 out of 6 pigs for the RUPS-100 group (Fisher exact test, P > 0.999). The mean duration of puncture was shorter in the Liverty™ group versus the RUPS-100 group (12.3 ± 4.5 min vs. 16.2 ± 8.5 min), but without significant statistical difference (two sample t test, P = 0.359). The cannula angle was adjusted 69% of passes in the Liverty™ group, which was significantly higher than that in the RUPS-100 group (12%, P = 0.004). Overall, the TIPS procedural performance was comparable between the groups. Both sets were safe. No intraabdominal hemorrhage, vascular injuries, tissue or organ injuries, porto-biliary fistula, biliary peritonitis, and infection or abscess occurred in either group.ConclusionThe Liverty™ set is safe and has similar procedural metrics to the COOK® RUPS-100 set. It allows in situ adjustment of the angle of the stiffening cannula without increasing procedure time and lessens the occurrences of periprocedural complications.Graphical

Incidentally portal vein penetration during cannulation in endoscopic retrograde cholangiopancreatography: a case report

Abstract Portal vein cannulation is a very rare complication of endoscopic retrograde cholangiopancreatography (ERCP). In most reported cases, the event was managed safely with immediate catheter, guidewire withdrawn and procedure termination. Here, we report an unusual case of portobiliary fistula created during ERCP. To our knowledge, this is the first report of such case managed with immediate surgical biliary exposure.

Iatrogenic Portobiliary Fistula following Endoscopic Biliary Stent Placement: A Case Series and Review of the Literature

Iatrogenic portobiliary fistula is a rare adverse event following endoscopic biliary stent placement. Damage to the portal vein following endoscopic biliary stent placement has previously only been reported as single case reports. Management has ranged from conservative monitoring to surgery. Here, the authors present 4 cases of inadvertent endoscopic placement of a biliary stent into the portal vein. Interventional radiology was called to assist in the management of each of these cases. The experience presented here in conjunction with review of the previously reported cases helps shed light on potential management strategies if this adverse event is encountered in the future.

Portobiliary fistula on single-operator cholangioscopy.

Portobiliary fistula on single-operator cholangioscopy.

S1795 Portobiliary Fistula on Single Operator Cholangioscopy

Introduction: Portobiliary fistula formation is an exceedingly rare complication following endoscopic retrograde cholangiopancreatography (ERCP), with a scarcity of cases reported in scientific literature. Patients may present with ensuing—often fatal—gastrointestinal hemorrhage with challenges in diagnosis and management as a result. Case Description/Methods: We present a case of 78-year-old male who was found to have opacification of vascular structures on intraoperative cholangiography during laparoscopic cholecystectomy. This was concerning for the development of a biliary-vascular fistula. The patient had recently undergone ERCP with biliary stent placement at an outside facility for choledocholithiasis. Gastroenterology was consulted for endoscopic evaluation. An ERCP was performed. Selective biliary cannulation was achieved, and contrast was injected to identify an irregularity in the distal common bile duct with upstream dilatation up to 13 mm. No clear contrast extravasation was noted in the biliary tree. The biliary tree was then swept using a 15 mm extraction balloon with successful removal of gallstones and sludge. Despite multiple contrast injections, extravasation was not seen, as previously noted on intraoperative cholangiography. Therefore, single operator cholangioscopy was introduced and advanced to the hilum of the common hepatic duct. Examination revealed a small defect in the common bile duct communicating with a thrombosed vascular structure, likely a branch of the portal vein (Figure). After a multidisciplinary discussion with surgery service, a fully covered 10 mm by 8 cm metallic stent was placed across the defect, anchored by a second 7 French by 10 cm double-pigtail plastic stent, with trans-papillary drainage. Discussion: We present a novel approach for the identification and management of portobiliary fistulas. Our case demonstrates the utility of biliary stents in the management of this disease. Our patient tolerated the procedure well with no post-operative complications.Figure 1.: Portobiliary Fistula on Single Operator Cholangioscopy.

Transbiliary embolization of an iatrogenic porto-biliary fistula, a challenging complication

Portobiliary fistulas are a rare complication of percutaneous transhepatic biliary procedures that could result in hemorrhage or sepsis. Hence we present a case of a transhepatic biliary drainage insertion in a patient with an underlying Bismuth type IV cholangiocarcinoma which resulted in a portobiliary fistula. Portobiliary fistula management is controversial. Moreover, to the best of our knowledge, there are few cases in the English literature reporting successful treatment. This case was successfully managed by controlled transbiliary embolization of a portal branch without compromising the main portal vein or bile ducts. Keywords: Biliary procedures; Cholangiocarcinoma; Embolization; Complications.

S1529 Occult Portobiliary Fistula Following Percutaneous Liver Biopsy

INTRODUCTION: Percutaneous liver biopsies are commonly performed procedures in the diagnostic workup or staging of liver diseases, and bleeding is the most important complication. Hemobilia is defined as bleeding into the biliary tree, and is a rare complication of liver biopsy that classically presents with a triad of GI bleeding, abdominal pain, and jaundice. CASE DESCRIPTION/METHODS: A 44-year-old male underwent an uneventful liver biopsy for workup of hepatic steatosis. The next day he presented to the ER with RUQ abdominal pain and jaundice. Vital signs were normal and physical examination revealed scleral icterus and epigastric tenderness. Liver function tests showed AST and ALT of 2248 U/L and 2915 U/L, respectively, alkaline phosphatase of 200 U/L, and total bilirubin of 23.3 mg/dL with direct bilirubin of 13.9 mg/dL. CT scan revealed small hemoperitoneum and diffuse hepatic steatosis. Ultrasound with doppler showed normal biliary and intrahepatic ducts and patent portal and hepatic veins with normal blood flow. On the fourth hospital day, MRCP revealed moderate right intrahepatic biliary ductal dilatation with associated hemobilia to the level of the biliary confluence (Figure 1). MRI with contrast revealed completely thrombosed right portal vein and branches, and persistent right intrahepatic biliary ductal dilatation (Figure 2). Oral anticoagulation was considered; however, the gastroenterology team felt the liver biopsy caused an iatrogenic portobiliary fistula, leading to the formation of the portal vein thrombus which may have helped seal the fistula. Therefore, the decision was made to hold anticoagulation and discharge the patient. Liver function tests one month later revealed AST and ALT of 20 U/L and 70 U/L respectively. Repeat MRI showed a reduction of right intrahepatic biliary dilation, and chronic right portal vein thrombus with recanalization and mild cavernous transformation (Figure 3). DISCUSSION: Given the biliary dilation on MRCP, we suspect that a blood clot at the biliary confluence caused an obstruction leading to acute severe rise in AST, ALT and direct hyperbilirubinemia. Due to the risk of further bleeding and possible tamponade effect of clot, anticoagulating the patient may have worsened the situation. Portobiliary fistulas leading to hemobilia are a rare complication of percutaneous liver biopsy. While GI bleeding, jaundice, or abdominal pain post-biopsy should prompt a diagnostic workup, it should also be kept in mind that there could be uncommon presentations of hemobilia.Figure 1.: MRCP showing moderate right intrahepatic biliary ductal dilatation with associated hemobilia.Figure 2.: Contrast enhanced MRI showing thrombosed right portal vein and branches, and right intrahepatic biliary ductal dilatation.Figure 3.: Follow-up MRI showing reduction of right intrahepatic biliary dilation, and chronic right portal vein thrombus.

Radiologic Assessment for Endoscopic US-guided Biliary Drainage.

Endoscopic US-guided biliary drainage (BD) is performed for various types of biliary obstruction and is mainly indicated for unsuccessful conventional transpapillary endoscopic retrograde cholangiodrainage. In endoscopic US BD, an extra-anatomic drainage route between the gastrointestinal (GI) tract and the biliary system is created with a covered metallic stent or plastic stent. Procedural types of endoscopic US BD include hepaticogastrostomy, hepaticojejunostomy (after gastrectomy), choledochoduodenostomy, hepaticoduodenostomy, and endoscopic US-guided gallbladder drainage. The technical and clinical success rates of endoscopic US BD are reported to be 94%-97% and 88%-100%, respectively. CT is crucial both in preprocedural assessment and postprocedural monitoring. CT is used to determine the indications for endoscopic US BD, which include the type of biliary obstruction, collateral vessels in the puncture route, ascites, the volume of the liver segment, the distribution of an intrahepatic tumor, and GI tract patency. After endoscopic US BD, common subclinical findings are a small amount of intraperitoneal gas, localized edematous change in the GI tract, a notch in the placed stent, and localized biliary dilatation caused by stent placement. Stent malfunction after endoscopic US BD is caused by impaction of debris and/or food, stent migration into the GI tract, or tumor overgrowth and/or hyperplasia. Complications that can occur include internal stent migration, intraperitoneal biloma, arterial bleeding or pseudoaneurysm, perforation of the GI tract, and portobiliary fistula. The incidence of clinical endoscopic US BD-related complications is 11%-23%. ©RSNA, 2020.

Fístula portobiliar como complicación mayor de biopsia hepática transpercutánea bajo marcación ecográfica

Woman of 71 years, in study of chronic liver disease, Child-Pugh A, computed tomography (CT) suggestive of cirrhosis, autoimmune hepatitis score probable. It was decided to perform a liver percutaneous biopsy for diagnosis and treatment. After the procedure, the patient presented a self-limited episode of hematemesis. Upper digestive endoscopy without blood or other injury, abdominal ultrasound without free liquid. The patient was hospitalized, evolving hemodynamically stable without new bleeding episodes. Medical discharge was decided after 24 hours of observation. The patient consults the next day at emergency room because of intense abdominal pain and anemia. CT Impressed a dilated bile duct with hyperdense content inside, so she was rehospitalized. The patient evolved with melaena and hypotension. Biliary hematoma due to arteriobiliary fistula was suspected. CT angiogram evidenced portobiliary fistula. It was managed with endovascular therapy but the patient remained hypotense with a requirement for vasoactive drugs and multi-organ dysfunction, and she finally died.

Stent-graft placement for treatment of massive hemobilia caused by porto-biliary fistula

Stent-graft placement for treatment of massive hemobilia caused by porto-biliary fistula

Transhepatic Cholangiostomyin in Nondilated Intrahepatic Bile Ducts

Aim. To improvethe efficiency of X-ray treatment of postoperative complications (duodenal and biliary fistulae, intraabdominal iatrogenic bile collections). Material and Methods. Percutaneous transhepatic biliary drainage was carried out in 11 patients with nondilated intrahepatic bile ducts. Failure of duodenal stump after previous stomach resections in 5 patients, presence of external biliary fistulae after surgery on gall bladder and common biliary duct in 3 patients and severe pancreonecrosis in 3 cases led to need of antegrade transhepatic cholangiostomy. Results. Antegrade transhepatic cholangiostomy gives an ability to close duodenal fistulae in 5 patients and biliary fistulae in 3 patients with iatrogenic injury of common biliary duct. Percutaneous transhepatic biliary drainage was used in treatment of 3 patients with severe pancreonecrosis. There were 2 complications of antegrade transhepatic cholangiostomy such as hepatic subcapsular hematoma and porto-biliary fistula which were cured effectively using minimally invasive methods (percutaneous drainage of hematoma and disintegration of porto-biliary fistula by filling of intrahepatic canal). Conclusion. Antegradetranshepaticcholangiostomy in case of nondilated intrahepatic bile ducts differs from traditional technique. Often it assumes contrasting of biliary tree using any available way and demands strict compliance of manipulation technology

Iatrogenic Portal Vein Injury During Biliary Stent Placement

Complications of endoscopic retrograde cholangiopancreatography (ERCP) beyond pancreatitis are rare. Reports on management of rare complications are also scarce. One such complication is internal biliary fistulas. Our case examines an incident of an iatrogenic portobiliary fistula (PBF) formation post biliary stent placement and discusses management. A 39 year-old female with congenital dwarfism presented with abdominal pain, distension and bilious vomiting for 2 weeks. The patient was afebrile and hemodynamically stable. On exam, she was without jaundice and in slight distress secondary to pain primarily focused in the right upper quadrant (RUQ) with guarding and rebound. Labs showed transaminitis, bilirubinemia and mild leukocytosis. CT of the abdomen demonstrated intra- and extra-hepatic biliary ductal dilation to the level of the ampulla of Vater and the common bile duct (CBD). Ultrasound of the RUQ demonstrated gallbladder stones with a 4mm wall and pericholecystic fluid. Out of concern for acute cholangitis, fluids and antibiotics were initiated and patient underwent ERCP. During ERCP, deep wire cannulation of the CBD and cholangiogram was performed confirming dilated biliary tree with distal CBD stone. Resistance was felt in passing the sphincterotome through the papillary orifice. A biliary sphincterotomy was performed without obvious complication. A balloon was inserted and sphincterotome removed. There was resistance passing the balloon catheter and sweeping of the stone was unsuccessful. A 7-French 7-cm stent was placed and resistance was met again with passing the stent. Fresh blood was noted upon stent deployment. The proximal stent appeared outside the biliary system on fluoroscopy. The stent was kept in place and emergent laparotomy and CBD exploration was performed. The stent was noted to pass from the CBD into the portal vein. The portal vein and ductal injury was repaired, and a T-tube placed. Intraoperative cholangiogram revealed retrograde filling without leaks. Post-operatively the patient did well without further complications and was discharged. Iatrogenic PBF in this case required surgical intervention as removal endoscopically could have led to exsanguination. As an alternative to surgery, interventional radiology via balloon could tamponade bleeding while the stent is replaced. Our case demonstrates that stent retention can allow for tamponade until further intervention is available, whereas removal could result in exsanguination.

Reduced complication rates of percutaneous transhepatic biliary drainage with ultrasound guidance.

We aimed to analyze the benefits of adding ultrasound (US) guidance to the standard fluoroscopically assisted percutaneous transhepatic biliary drainage (F-PTBD). We also performed a systematic literature review of success and complication rates of US-PTBD in a wide field of indications. We evaluated a total of 81 US-PTBDs carried out in our institution, 74% of which were part of the management of malignancy. In addition, we compared our results with those of a total of 5,272 procedures (3,779 F-PTBD and 1,493 US-PTBD) reported in the literature. US-PTBD was technically successful in 94% of attempts with a mean of 2.2 needle passes. Procedural success was achieved in 86% of cases. There were no procedure-related deaths or severe complications. Minor complications were catheter dislodgement (15%) as well as one case each of a porto-biliary fistula, hematoma, and biloma. A systematic review of the literature also showed that US-PTBD has a similar technical success rate to F-PTBD but lower median rates of severe early complications (0% versus 8%) and procedural death (0% versus 1%). Given our results and our review of the literature, US-PTBD is as effective as F-PTBD and has significantly lower complication rates. US-PTBD should be preferred to F-PTBD. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:400-407, 2017.

Percutaneous Management of Portal Vein Patency and Integrity Problems - Catheter Directed Local Thrombolysis, Stenting, Endoluminal RFA & Angioplasty by Balloon or Stenting

Purpose: Spectrum of PV patency and integrity percutaneous restoration techniques is presented. Material and methods: Total twenty patients with portal hypertension due to PV patency & integrity problem; among them percutaneous recanalization was attempted in fifteen patients with PV tumor thrombus using a novel endoluminal bipolar radiofrequency device. The procedure was completed in twelve of fifteen RFA cases; RFA was followed by balloon angioplasty (six cases) or vascular stent placement (six cases). In two cases catheter directed local thrombolysis was performed to acutely manifest fresh PV thrombosis, caused by thrombophylia and HCC. In two cases of pancreatitis induced PV thrombosis & stricture and one case of pancreatitis induced PV thrombosis & stricture and porto-biliary fistula, PV stenting was performed. The PV tributary was percutaneously accessed under US guidance and 5G guide catheter was manipulated through the obstruction using guidewire technique under DSA guidance. In case of thrombolysis thrombolytic agent was injected directly distal to the thrombus, the stenting procedure was completed by self-expanding vascular stent placement. Results: The technical success rate was 85.0%; in three cases (15.0%) wire conduction through the organized thrombus was impossible. Posprocedure portography documented significantly improved portal vein blood flow in all patients, to whom the procedure was completed. Porto-biliary fistula was successfully managed by percutaneous stenting. In three cases postprocedure bleeding was documented, which led to multiorgan failure and death in one case. Conclusions: The management of PV patency and integrity problems by percutaneous stenting or endoluminal RFA and stenting is an effective technique; it should be suggested as a treatment option for otherwise incurable patients and might be used as a bridge for further treatment. Post-procedure intraperitoneal bleeding is a possible life-threatening complication which should be prevented by procedure track ablation or embolization.

An unusual complication during papillotomy: Breaking of papillotome cutting wire and its subsequent penetration of papilla

AbstractThousands of papillotomies are done word wide in day today practice by Gastroenterologists. Papillotomy is a procedure which is fascinating by its results but frightening by its complications. There are some usual, unusual and unknown complications. The usual ones are Pancreatitis, hemorrhage, perforation and biliary sepsis. The unusual complications include subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum, migration of stents, systemic air embolism, portobiliary fistula, placement of ENBD in portal vein, basket impaction and breakage of basket etc. We report a forty year old female with an unknown complication; the breakage of papillotome cutting wire and its subsequent penetration of papilla.

Portobiliary fistula: successful transcatheter treatment with embolisation coils

Although portobiliary fistula is a recognised complication of percutaneous transhepatic biliary drainage, it is extremely uncommon and can result in haemobilia. Herein, we present a case of complicated transhepatic biliary drainage catheter insertion in a patient with underlying hepatitis B liver cirrhosis, which resulted in a portobiliary fistula. The patient had a preoperative transhepatic biliary drainage procedure done prior to a Whipple's operation for a large, obstructive, gastrointestinal stromal tumour of the duodenum. To the best of our knowledge, this is the first case in the English medical literature reporting the successful treatment of portobiliary fistula by embolisation of its tract with embolisation coils, without compromising the portal vein or bile ducts.

Endoscopic ultrasound diagnosis of an ERCP-related portobiliary fistula

Endoscopic ultrasound diagnosis of an ERCP-related portobiliary fistula

Portobiliary fistula: unusual complication of wire-guided cannulation during endoscopic retrograde cholangiopancreatography

Portobiliary fistula: unusual complication of wire-guided cannulation during endoscopic retrograde cholangiopancreatography