Authors: Shiro Miyayama, Masashi Yamashiro, Rie Ikeda, Takumi Sugiura, Seitaro Ishikawa, Naoko Sakuragawa, Takuro Terada, Taku Sanada
Categories: Pictorial Essay, bile duct injury, interventional procedure, multidisciplinary approach
Source: Interventional Radiology
Percutaneous Interventional Procedures for Bile Duct Injuries
Authors: Shiro Miyayama, Masashi Yamashiro, Rie Ikeda, Takumi Sugiura, Seitaro Ishikawa, Naoko Sakuragawa, Takuro Terada, Taku Sanada
Abstract
Percutaneous interventions are widely performed for bile duct injuries due to surgery, trauma, and local ablation or transarterial chemoembolization for hepatocellular carcinoma. Most bilomas can be treated with percutaneous drainage alone, but additional biliary drainage or plastic stenting in the common bile duct, dilation of the coexisting biliary stricture, or embosclerosis is also required for refractory bilomas. For bile duct occlusions or disruptions, percutaneous transhepatic biliary drainage and long-term catheter placement across the affected segment are recommended. In addition, intrahepatic biliary ablation and/or percutaneous transhepatic portal vein embolization is effective for refractory bile leaks. Percutaneous drainage is required for infected necrotized hepatocellular carcinoma due to ascending cholangitis after transarterial chemoembolization. Plastic stent placement is also recommended for main bile duct strictures caused by transarterial chemoembolization.
Introduction
Interventional procedures are widely performed for various bile duct disorders, including bile duct injuries. Complex bile duct injuries usually require multidisciplinary management including interventional radiology, gastroenterology, and hepatobiliary-pancreatic surgery, and the most effective and minimally invasive treatment approach should be selected on the basis of the hepatic function and liver volume affected by the bile duct injury [1-7].
Successful interventions can avoid additional invasive treatments and lead to a favorable quality of life for patients. Therefore, we should be aware of the role and techniques of percutaneous interventional procedures in the treatment of bile duct injuries. The aim of this study was to describe several representative cases of bile duct injuries involving treatment with interventional procedures.
Etiology of Bile Duct Injury
The most common cause of bile duct injury is hepatobiliary-pancreatic surgery, and the Strasberg classification system is most widely used in clinical practice to guide management decisions (Figure 1) [3, 4, 7]. The Nagano classification is also used to categorize the bile leakage after hepatectomy into four types (Table 1) [5]. The reported incidence of iatrogenic bile duct injury is 0.1% to 0.2% in open cholecystectomy (Figure 2), 0.4 to 0.6% in laparoscopic cholecystectomy, and 4.8% to 7.6% in hepatic resection (Figures 3-7) [1, 2]. It develops more frequently in patients with an aberrant right hepatic bile duct (Figures 2 and 3) [3, 8]. Anastomotic bile duct occlusion or leak can develop after hepaticojejunostomy or choledochojejunostomy (Figure 8) [1]. Approximately 25%-32% of iatrogenic bile duct injuries during laparoscopic cholecystectomy are identified intraoperatively but are more commonly recognized in the postoperative period, days, months, or rarely, years later [3]. Post-traumatic bile duct injury occurs with delayed onset owing to bile duct necrosis caused by interruption of the segmental blood supply to the bile duct wall (Figure 9) [9, 10]. Local ablation therapy for malignant liver tumors can damage the bile duct owing to necrosis of normal liver parenchyma, and biliary complications develop in 0.2%-8% of patients with HCC treated with radiofrequency ablation [11]. Biloma and/or bile duct stricture also develops after transarterial chemoembolization (TACE) for HCC due to damage of the peribiliary vascular plexus (Figures 10 and 11) [12-14]. The reported incidence of main bile duct stricture is 6.2% in patients who undergo selective TACE of the caudate or medial subsegmental hepatic artery [13] because the first and/or second branch of these arteries supplies the main hepatic duct or connects with the 3 and 9 o'clock arteries [13, 14]. Moreover, some bilomas can rarely occur spontaneously [11].
![Figure 3.: Disruption of the aberrant right hepatic duct during hepatectomy (Nagano classification type D).A. Two-dimensional magnetic resonance cholangiopancreatography performed before surgery showed that the bile duct of the anterior inferior liver segment (B5) directly communicated with the common hepatic duct (arrow). B. Subtotal stomach-preserving pancreaticoduodenectomy was performed for pancreatic head carcinoma, and bile discharge continued through the surgical drain. Fistulography through the drainage tube performed on day 18 post-surgery depicted the accessory hepatic duct (not shown). Percutaneous transhepatic biliary drainage (PTBD) of the isolated B5 was performed on day 21, and the disruption of B5 was confirmed (arrow). The arrowhead indicates the surgical drain. C. Thereafter, intrahepatic biliary ablation with a mixture of ethanol and iodized oil (10:1 ratio) was performed through the PTBD route under balloon occlusion on day 29. The arrow indicates a microballoon. Bile leak resolved the day after the procedure, and the drainage tube and PTBD catheter were withdrawn on day 37. The patient died from tumor progression 16 months postoperatively without recurrence of bile leak. Figure 3B reprinted from Miyayama et al. [28], 2020. An Open Access article (CC BY 4.0).](2432-0935-10-e2025-0013-g003.jpg)
![Figure 5.: Disruption of the left hepatic duct during hepatectomy (Nagano classification type C).A. The patient underwent right hepatectomy for liver metastasis from colonic carcinoma in another hospital. On day 54 post-hepatectomy, the patient presented with septic shock, and open drainage of an abscess at the hepatic hilum was performed. Bile leak continued through the surgical drain, and endoscopic retrograde cholangiopancreatography (ERCP) showed the disruption and stricture of the left hepatic duct (arrow). The arrowhead indicates the surgical drain. B. The patient was transferred to our hospital, and percutaneous transhepatic biliary drainage (PTBD) was performed. The left hepatic duct was disrupted, and a guidewire was only advanced into the abscess cavity through the laceration; therefore, a 7.2-F drainage catheter was placed in the abscess through the left biliary system (arrow). C. Four days later, the disrupted left hepatic duct could be traversed by the rendezvous technique, and a 10-F internal-external drainage catheter was then placed through the PTBD route (not shown). Thereafter, the internal-external catheter was exchanged for a larger catheter step by step up to a 16-F catheter. The arrow indicates the drainage catheter in the abscess cavity. D. A cholangiogram obtained after placement of a 16-F catheter for 8 weeks showed the disappearance of extravasation and improvement of the stricture. Therefore, the drainage catheter was withdrawn. E. However, 2 weeks after catheter withdrawal, the patient presented with fever. ERCP showed bile leak (arrowhead) and stricture (arrow) at the same site, and a 7-F nasobiliary drainage catheter was then placed (not shown). F. Two bare metallic stents were deployed at the stricture 12 days later (not shown). However, fever recurred 282 days after stenting, and ERCP revealed recurrence of the bile leak and stricture at the same site (not shown). Therefore, a covered metallic stent (arrow 1) was placed, and an additional bare stent (arrow 2) was also deployed on the inside owing to kinking of the covered stent. The arrows 3 and 4 indicate the previously placed stents. The edge of each stent is indicated by each arrow. G. Contrast-enhanced CT performed 18 years and 3 months after covered stent placement showed that the stents were patent. Figure 5A, 5D, and 5F reprinted from Miyayama et al. [22], 2017. An Open Access article (CC BY 4.0).](2432-0935-10-e2025-0013-g005.jpg)
Clinical Symptoms and Treatment Strategies of Bile Duct Injury
Most bile duct injuries related to surgery or trauma present with bile leak and bile duct stricture or occlusion, and intra-abdominal abscess, cholangitis, and lobar atrophy or secondary biliary cirrhosis due to long-term obstruction can develop [1-10]. Local ablation therapy and TACE may cause a biloma and bile duct stricture [11, 15], and infection of necrotized HCC through the bile duct also can develop after TACE [16]. Treatment options should be considered on a case-by-case basis, depending on the etiology and magnitude of injury, associated complications, and the patient's condition [7]. Among iatrogenic bile duct injuries, Strasberg type A injuries are usually manageable using endoscopic or percutaneous procedures; type C and D injuries may require either surgical or percutaneous repair depending on the anatomical conditions, and type B and E injuries generally require surgical repair [7]. Moreover, Nagano classification type D bile leakage cannot be healed by simple drainage alone, and surgical or non-surgical interventions are required [5]. Therefore, a multidisciplinary approach is required for the optimal management of complex bile duct injuries.
Interventions for bilomas
Bilomas related to surgery or blunt trauma should be drained promptly because delayed drainage can increase the incidence of serious complications, such as abscess formation, cholangitis, and sepsis [3]. Small bilomas without infection after HCC treatment need no additional treatment [11]; however, symptomatic or infected bilomas require treatment [15]. Most bilomas can be treated with percutaneous drainage catheter placement under sonographic or CT guidance. Combined endoscopic placement of a plastic stent in the common bile duct or percutaneous transhepatic biliary drainage (PTBD) is also performed for symptomatic bilomas because intrahepatic diversion of the biliary system can reduce intrabiliary pressure by redirecting bile flow away from the injured bile duct [3, 15].
However, withdrawal of a drainage catheter in the biloma is impossible when bile discharge continues through the catheter. In this situation, a stricture usually exists in the proximal portion of the injured bile duct [17]. Therefore, treatment for the coexisting biliary stricture is necessary to withdraw the drainage catheter. The standard treatment varies depending on each etiology of the stricture, with placement of a plastic stent or covered metallic stent and/or cholangioplasty with a balloon catheter for benign lesions (Figures 2, 4-7, 9 and 11) and metallic stent placement for malignant tumors (Figures 8 and 12). In a biloma communicating with the biliary system, it is possible to access the bile duct from the biloma through the communication (Figure 12) [18]. If there is no obvious communication between the biloma and biliary system, additional PTBD of the affected bile duct is required. Embosclerosis with ethanolamine oleate or fibrin glue is also effective for bilomas refractory to the abovementioned treatment (Figure 10) [16, 17].
Interventions for bile duct occlusions or disruptions
Complete ductal ligation with surgical clips or sutures during surgery generally requires re-operation, including primary ductal repair, end-to-end biliary anastomosis, and biliary-enteric anastomosis [4]. In addition, most major bile duct disruptions cannot be healed by simple drainage alone. However, bile duct occlusion or disruption regardless of the etiologies is indicated for endoscopic or percutaneous biliary drainage even in patients who are primarily indicated for surgical repair because it allows re-operation with optimal timing after improvement of a patient's general condition [5]. A cholangiogram obtained by endoscopic retrograde cholangiopancreatography and/or PTBD can also directly provide the anatomic delineations of the injured bile duct for treatment planning [4, 7]. Moreover, some bile duct occlusions or disruptions can be treated non-surgically by transhepatic and/or endoscopic approaches (Figures 2-9).
In the treatment of bile duct stricture or occlusion through the PTBD route, crossing the affected segment with a catheter-guidewire system is the first step. If this fails with conventional devices, the use of a microcatheter-guidewire system can facilitate crossing of the occluded segment (Figures 2 and 9) [10]. In addition, endoscopic placement of a nasobiliary drainage catheter on the opposite side of the occlusion facilitates identification of the proximal biliary system and guidance for the correct direction of recanalization (Figure 9) [10]. Sharp recanalization with a needle or stiff end of a guidewire is also performed for an anastomotic bile duct occlusion that cannot be traversed by the guidewire [19, 20]. We encountered a case in which sharp recanalization was unsuccessful, but the tip of a drainage catheter placed in the bile duct was dislodged and unintentionally penetrated the occluded hepaticojejunostomy (Figure 8).
In patients with a large bile duct laceration, a guidewire inserted either through PTBD or the endoscopic transpapillary route can easily be advanced outside the bile duct (biloma) through the laceration. Therefore, a guidewire advanced through one route can be grasped in the biloma by a snare catheter navigated through another route, and through-and-through access can be established (rendezvous technique) (Figures 4-6, Video) [19, 21].
If a guidewire can cross the occluded or disrupted segment, a large internal-external catheter or plastic stent is left in place to bridge there for a relatively long period. The plastic stent can be exchanged by a transpalillary route or through the biliary-enteric anastomosis when an endoscope can access the stent (Figures 5 and 6). Although there is no standard consensus on the optimal duration of catheterization or optimal catheter/stent size, existing data suggest that a duration of longer than 4 months is associated with improved ductal patency [6]. Our treatment strategy is to place a catheter across the affected bile duct for longer than 6 weeks (Figures 2 and 4-9) [22]. If the stricture and/or bile leak is still shown on a cholangiogram obtained 6 weeks later, catheter placement is extended until the stricture and/or bile leak resolves or additional interventions are considered.
Interventions for bile duct strictures refractory to standard treatment
Placement of a bare metallic stent is not recommended for benign bile duct occlusions or strictures, but covered metallic stents, especially retrievable ones, are a promising alternative for selected benign bile duct strictures refractory to standard treatment [23, 24]. We placed an unretrievable covered metallic stent in the common hepatic duct stricture caused by iatrogenic bile duct disruption during right hepatectomy that was refractory to long-term catheter placement and uncovered metallic stent placement, and it has been patent for more than 18 years (Figure 5) [22].
Biodegradable biliary stents can also show complete hydrolysis within 6 months and offer a satisfactory patency rate similar to that of fully covered self-expandable metallic stents. Excellent results on using these stents for benign biliary strictures refractory to cholangioplasty have been reported [25].
Interventions for bile leaks refractory to standard treatment
In cases with bile leak from an anastomotic site refractory to long-term catheter placement, the usefulness of injecting autologous fibrin through a catheter placed near the leaking anastomosis has been reported [26].
Intrahepatic biliary ablation is an effective treatment for bile leak. The reported sclerosing agents are ethanol, n-butyl-2-cyanoacrylate, and 50% acetic acid [5, 7]. Among them, ethanol is the most used, and it destroys the biliary epithelium, permeates the parenchyma, and induces hepatocyte degeneration when selectively injected into the bile duct [27]. To perform this procedure safely and effectively, it is helpful to add iodized oil (Lipiodol 480, Guerbet Japan, Tokyo, Japan) to ethanol to make the mixture radiopaque and allow monitoring of its distribution under fluoroscopy. The use of a balloon catheter can also prevent overflow of ethanol outside the bile duct [7]. We mix ethanol and iodized oil in a 1 ratio and inject it for a period of 10-20 minutes under ballon occlusion (Figure 3). Thereafter, the mixture is aspirated, and the injection is repeated 2-3 times [28]. If bile leak continues after the procedure, it is repeated at 1-3-day intervals until the bile leak stops [29].
Percutaneous transhepatic portal vein embolization (PTPE) is another treatment option for refractory bile leak because it eliminates liver function in the liver segment drained by the leaking bile duct [5, 29, 30]. Previous reports described successful treatment of bile leak with biliary ablation when the bile leak volume was 50-150 mL/day. In contrast, PTPE was performed when the bile leak was 40-50 mL/day [29]. Another strategy involves the indication of biliary ablation for bile leak from less than one hepatic segment, and PTPE is suitable for bile leak from one or more hepatic segments. In addition, PTPE should only be performed in patients who are in good health and have sufficient residual liver function to avoid liver failure [5]. We embolize the portal vein with a mixture of ethanol and iodized oil (10:2 ratio), and it is injected for 10 minutes under balloon occlusion (Figure 6). If one treatment is not effective for intractable bile leak, the other should be attempted, although the order of each treatment differs among reports [5, 29, 30]. Intrahepatic biliary ablation is simpler and less invasive than PTPE; therefore, it should be performed first when the draining territory of the disrupted bile duct is small.
Interventions for bile duct injuries following TACE for HCC
A previous report showed that HCC tissues necrotized by TACE were excreted into the biliary system in 10.8% of patients with a tumor >5 cm [16]. This indicates that a communication (fistula) between the necrotized tumor and adjacent biliary system is created by TACE owing to ischemic necrosis of the bile duct wall. Ascending cholangitis through this communication can cause tumor infection and sepsis; therefore, percutaneous drainage of the necrotized tumor is required to control the infection. If the fistula between the tumor and bile duct is revealed by contrast material injection through the drainage catheter, balloon dilatation of the fistula with an angioplasty balloon catheter is effective in draining the necrotized tumor tissues into the bile duct (Figure 10).
Main bile duct strictures after TACE occasionally cause jaundice [2-14]. Intrahepatic bile duct dilatation is also a significant risk factor for bilomas and/or abscesses after TACE [14]. Symptomatic strictures, in addition to asymptomatic strictures in the area where additional TACE is planned, should be treated. However, metallic stent placement frequently leads to bile duct complications after TACE [13]. Therefore, placement of a plastic stent is recommended for the main bile duct stricture caused by TACE, although multiple plastic stent exchanges may be required during the treatment course [14]. If the stricture is too hard to endoscopically place a plastic stent, PTBD and cholangioplasty of the stricture allow successful endoscopic plastic stent placement (Figure 11).
Conclusions
Percutaneous interventional procedures play an important role in the management of bile duct injuries. Successful interventional procedures for bile duct injuries can avoid additional invasive treatments; therefore, we should be familiar with these techniques.
Author Contributions
SM was primarily involved in the drafting of the manuscript and creation of figures. SM, MY, RI, TS, and SI were involved in the interventional procedures. NS was involved in image analysis. TT and TS were involved in patient care. All authors reviewed the manuscript.
Conflicts of Interest
There are no conflicts of interest.
Disclaimer
Shiro Miyayama is one of the Editorial Board members of Interventional Radiology. This author was not involved in the peer-review or decision-making process for this paper.
Institutional Review Board
This was a pictorial essay with no change in patient care, and institutional review board approval is not required at our institution for this type of article. Written informed consent was obtained from all patients before the procedure. All manuscript preparation processes complied with the Declaration of Helsinki.