Abstract

Aim: was to assess feasibility and effectiveness of using special methods for preventing of port-biliary fistula formation, at all stages of percutaneous transhepatic cholangiostomy (PTC).

Material and methods: we analyzed results of 3786 cholangiostomies with Seldinger technique, performed during the period from 1995 to 2019. Primary puncture of target bile duct was performed with a 17,5-18G needle for Amplaz guidewire 0,035’’ with a safe J-tip. With benign lesion of the biliary tree, 2066 cholangiostomies (54.6%) were performed, with tumor – 1720 (45,4%).

Results: significant hemobilia was registered in 21 patients (0.55%) from the analyzed group (3786 PTC), while in 3 cases arteriobiliary fistula was diagnosed, in 16-portbiliary fistula, 2 - biliary-venous fistula. The frequency of portоbiliary fistulas was 0,42%. The presence of blood impurities during aspiration from bile ducts was considered as obvious sign of portоbiliary fistula. Prevention of the formation of port-biliary fistula was realized by using well-guided puncture needles of large diameter (17,5-18G), including use of the «open needle» technique and timely changing the puncture trajectory during puncture of the vessel before penetration of the bile duct. Discredited access was used only for cholangiography with simultaneous puncture of bile ducts with a second needle along a different path and control of the severity of hemobilia according to the established second conflict-free cholangiostoma. All portоbiliary fistulas were closed conservatively.

Conclusion: the use of special methods of prophylaxis, determined a low frequency of portоbiliary fistulas - 4.2 port-biliary fistulas per 1000 percutaneous transhepatic cholangiostomy (0,42%), as well as their relatively benign nature (marginal wound of lateral portal vein branches), which did not require the use of embolization techniques.

References

1.     Shiau EL, Liang HL, Lin YH. (et al.). The Complication of Hepatic Artery Injuries of 1,304 Percutaneous Transhepatic Biliary Drainage in a Single Institute. J Vasc Interv Radiol. 2017 Jul;28(7):1025-1032. doi: 10.1016/j.jvir. 2017.03.016.

2.     Dolgushin BI, Virshke ER, Cherkasov VA, Kukushkin VA, Mkrtchjan GS. Selective Embolization of Hepatic Arteries in Bleeding Complications of Percutaneous Transhepatic Biliary Dranage. Annaly khirurgicheskoy gepatologii. Annals of HPB surgery. 2007; 12(4): 63-68 [In Russ].

3.     Aung TH, Too CW, Kumar N (et al.). Severe Bleeding after Percutaneous Transhepatic Drainage of the Biliary System. Radiology. 2016 Mar; 278(3):957-8. doi: 10.1148/ radiol.2016151954.

4.     Saad WE, Wallace MJ, Wojak JC (et al.). Quality improvement guidelines for percutaneous transhepatic cholangiography, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv Radiol. 2010 Jun; 21(6): 789-95. doi: 10.1016/j.jvir.2010.01.012.

5.     Dietrich CF, Lorentzen T, Appelbaum L (et al.). EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III-abdominal treatment procedures (Long Version). Ultraschall Med. 2016 Feb;37(1):E1-E32. doi: 10.1055/s-0035-1553917.

6.     Mortimer AM, Wallis A, Planner A. Multiphase multidetector CT in the diagnosis of haemobilia: a potentially catastrophic ruptured hepatic artery aneurysm complicating the treatment of a patient with locally advanced rectal cancer. Br J Radiol. 2011, May; 84(1001):e95-8. doi: 10.1259/bjr/20779582.

7.     Quencer KB, Tadros AS, Marashi KB (et al.). Bleeding after Percutaneous Transhepatic Biliary Drainage: Incidence, Causes and Treatments. J Clin Med. 2018 May 1;7(5). pii: E94. Doi 10.3390/jcm7050094.

8.     Chanyaputhipong J, Lo RH, Tan BS, Chow PK Portobiliary fistula: successful transcatheter treatment with embolisation coils. Singapore Med J. 2014 Mar; 55(3):e34-6.

9.     Madhusudhan KS, Dash NR, Afsan A (et al.). Delayed Severe Hemobilia Due to Bilio-venous Fistula After Percutaneous Transhepatic Biliary Drainage: Treatment With Covered Stent Placement. J Clin Exp Hepatol. 2016 Sep; 6(3):241-243.