Portobiliary fistula: successful transcatheter treatment with embolisation coils

Abstract

C a s e R e p o r t e34 I NTRO D U C TIO NBiliary drainage procedures are widely used in the management of biliary-related diseases, benign or otherwise. As percutaneous transhepatic biliary drainage (PTBD) is an invasive procedure, it is not risk-free. Although no significant difference in the success rate of cannulation in patients with dilated and non-dilated biliary systems has been reported, PTBD-related complications are found to be higher when performed on non-dilated biliary systems and small cirrhotic livers.(1,2) Portobiliary fistula is a recognised, but uncommon, complication of PTBD and can result in significant haemobilia. (3,4) We herein present a case of portobiliary fistula following PTBD catheter insertion in a patient with an underlying history of hepatitis B liver cirrhosis. The portobiliary fistula was successfully managed using embolisation coils to occlude the fistulous tract. CA S E R EPO RTA 50-year-old man with underlying hepatitis B liver cirrhosis was investigated for anaemia. He was found to have a 5-cm fluorodeoxyglucose-avid duodenal mass arising from the second part of the duodenum, consistent with gastrointestinal stromal tumour (GIST). No distant metastasis was found.Transhepatic cholangiography was performed, together with preoperative insertion of a biliary drainage catheter before pancreaticoduodenectomy (i.e. Whipple's operation).The patient's liver was found to be grossly cirrhotic.Successful access to the left hepatic lobe segment 3 duct was achieved using a 22G Chiba needle (Pajunk GmbH, ABSTRACT 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. Keywords: embolisation coil, haemobilia, portobiliary fistula, transhepatic biliary drainageSingapore Med J 2014; 55(3): e34-e36 doi: 10.11622/smedj.2014039

Diagnosis and Management of Complications from Percutaneous Biliary Tract Interventions

“…If the injury is that to a small peripheral portal venous radicle, reinsertion of a larger catheter through the same tract with the side holes positioned deeper into the biliary tree will help solve the problem, as use of the larger tube will lead to a tamponade of the bleeding and allow the tract to heal. However, if there is transgression of a larger central portal venous radicle-in a compromised (ie, resected, cirrhotic, or transplanted) liver especially-coil embolization of the tract (Fig 14) on either side of the transgressed vein at the time of sheath withdrawal can facilitate a tamponade of the tract and simultaneously help maintain portal venous radicle patency (23). Stent graft insertion also can be considered (24).…”

Delayed Severe Hemobilia Due to Bilio-venous Fistula After Percutaneous Transhepatic Biliary Drainage: Treatment With Covered Stent Placement

“…The type of intervention depends on the severity of hemorrhage. 9 For minor hemorrhage due to bilio-venous fistula, where patient is hemodynamically stable, we often close the external end of the internal/external drainage catheter to create a tamponade effect and this controls the hemorrhage as portal vein is a low pressure system. Increasing the size of the catheter may also help.…”

“…8 In cases of larger fistula with severe bleeding causing hemodynamic instability, immediate closure of the fistulous communication becomes necessary. 9,11 The cause of fistula in such a situation is difficult to identify as it can result from either tumor invasion or catheter erosion into the vein or both. A contrast enhanced CT scan may be performed to identify the exact cause.…”

“…A contrast enhanced CT scan may be performed to identify the exact cause. 9 However, in both the cases, management will be same.…”

“…6,7 Biliovenous fistula is a rare complication, seen in less than 0.5% cases, with few cases reported in literature. 4,[8][9][10][11][12] These cases are either managed conservatively or by radiological interventions in the form of balloon occlusion, coiling or covered stent placement depending on patient's hemodynamic status. 4,[8][9][10][11] We report a case of 56-year-old male with carcinoma of gall bladder, who developed bilio-venous fistula 3 weeks after PTBD and presented with features of hemodynamic shock and was managed by placement of biliary covered stent.…”