Percutaneous Transhepatic Extra-Anatomical Biliodigestive Anastomosis of an Excluded Accessory Right Posterior Bile Duct after Pancreaticoduodenectomy

Abstract

Biliary complications, such as leaks and obstructions, pose significant postoperative challenges, especially when endoscopic access is unfeasible. This case report highlights the exclusive use of a percutaneous technique to establish an extra-anatomical biliodigestive anastomosis for a persistent biliary leak from an excluded right posterior bile duct following pancreaticoduodenectomy. A transhepatic approach was employed, redirecting bile flow via an internal-external drain and later stenting, achieving symptom resolution without surgical reintervention. This technique might be a viable alternative for managing complex biliary leaks, leveraging percutaneous methods to restore continuity. Long-term follow-up confirmed its success, suggesting further investigation into its safety and efficacy.

Keywords

interventional radiology - biliary drainage - cancer

Introduction

To prevent the need for surgical reintervention, and considering that endoscopy may not always be a viable postoperative option, other alternatives must be explored for treating excluded or transected biliary duct leaks.[1] [2] [3] This case report demonstrates the exclusive use of a percutaneous technique to establish an extra-anatomical biliodigestive anastomosis for an excluded accessory right posterior bile duct following a pancreaticoduodenectomy.

Case Description

Institutional review board approval was not required for this case report. An 80-year-old female patient experienced a persistent perihepatic collection after undergoing a recent pancreaticoduodenectomy for pancreatic cancer 3 weeks before the onset of symptoms ([Fig. 1A]). A magnetic resonance cholangiopancreatography (MRCP) was performed before the surgical intervention but did not identify any bile duct variant and before the initial interventional radiology (IR) procedure. However, the later MRCP was not informative due to the presence of surgical clips. The decision to proceed with the IR procedure was influenced by the acute clinical presentation and the urgent need to address symptoms.

Fig. 1 Percutaneous transhepatic biliodigestive anastomosis of an excluded accessory right posterior bile duct after pancreaticoduodenectomy in an 80-year-old woman. (A) A perihepatic collection is observed on this contrast-enhanced computed tomography (CT) (arrow). (B) The opacification of the external 10-F drain demonstrated an excluded accessory right posterior biliary duct (arrow). (C) The catheter sheath study also shown a fistula connecting the collection to the bowel (arrow). (D) A 5-F catheter was inserted over the wire from the right biliary duct to access the bowel through the fistula (arrow). A 10-F internal-external drain was placed for 2 months and the left external drain was removed. (E) The 10-F internal-external biliary drain was removed over a wire and two covered stents were placed to divert flow from the right leaking biliary system into the bowel (arrow). (F) A CT scan conducted 12 months after the procedure confirmed the resolution of the perihepatic collection and stent migration, and the patient remained symptom-free at the 18-month follow-up.

Initial attempts to address the condition involved externally draining the left perihepatic collection through a 10-F catheter, which resulted in the aspiration of bile. The patient manifested fluctuating fever, pain, and a daily bilious output of 100 mL. Initial serologic analysis showed an elevated bilirubin level of 0.6 mg/dL and a white blood cell count of 14.3 K/mcL. The drain was replaced in the perihilar collection ([Fig. 1B]). As the location of the leak remained unclear, a contrast injection was performed through the drain into the collection to confirm the communication between the biliary system and the perihepatic collection, while it is not standard practice. Contrast injection identified a retrograde opacification into the right posterior accessory biliary duct. In addition, a fistula connecting the collection and the bowel situated 3 cm away from the leak was identified during the catheter sheath study, positioned 6 cm from the bile duct ([Fig. 1C]).

Despite adequate drainage, persistent symptoms prompted the decision to internalize the drain for the patient's comfort. Endoscopic retrograde cholangiography was ruled out due to the recent surgery, leading to the choice of establishing a percutaneous transhepatic biliodigestive anastomosis to connect the right posterior biliary duct to the bowel. Access to the right posterior bile duct was achieved, and a 10-F biliary drain was inserted. A 5-F catheter was advanced over a guidewire to the fistula, followed by the placement of a 10-F, 40-cm internal-external biliary drain over the wire to redirect the flow from the leaking right biliary system into the bowel ([Fig. 1D]). The left external drain was removed. The procedure, lasting 1 hour, allowed for the patient's discharge on the first day postprocedure.

Subsequent follow-up was uneventful, with the patient successfully tolerating capping trials at home. Two months after the procedure, the right internal/external biliary drain was converted to two 8-mm covered stents (Viabil, Gore, United States) of lengths 4 and 6 cm ([Fig. 1E]). Two stents were placed to ensure complete coverage of the tract between the bile duct and bowel, minimizing the risk of restenosis or incomplete sealing of the leak. The decision to remove the right internal/external drain was confirmed by the absence of any leak through the biliary system following stent placement. A computed tomography scan conducted 5 weeks after the procedure confirmed the resolution of the perihepatic collection. The patient remained symptom-free at the 18-month follow-up, and the stents migrated by themselves after 8 months ([Fig. 1F]).

Discussion

Biliary complications, such as strictures and obstructions, are substantial risks of morbidity and mortality following liver surgery. When endoscopic access is not feasible, a percutaneous approach might be considered as an alternative to surgical interventions. Various methods for treating biliary injury include endoscopic bilioduodenal anastomosis, laser or radiofrequency-assisted techniques, and direct puncture methods. Each method has specific indications based on anatomical and clinical considerations but is appropriate for creating biliodigestive anastomosis when the distance between the bile duct and bowel is short, and the configuration allows for alignment.[1] [4] The percutaneous “extra-anatomic” bypass described here provides an additional approach to restoring continuity while avoiding surgical reintervention in cases involving longer defects or tortuosity.

The technique described in this case report involves exclusive percutaneous management using extra-anatomic navigation to locate and enter a fistula, leaving a drain in place for several months to stimulate fibrosis and facilitate the formation of a new bile duct. To prevent restenosis or leak, stenting was employed. While covered stents were used in this case, biodegradable stents might be a viable alternative in future scenarios, offering the advantage of spontaneous degradation. Biodegradable stents were not used due to limited availability and lack of familiarity with their use in our institution at the time, but this approach may be worth considering in future cases.

However, the mechanism of injury in this case likely occurred due to unrecognized aberrant biliary anatomy during pancreaticoduodenectomy, leading to the exclusion of the right posterior accessory bile duct. A careful review of preoperative imaging, including MRCP, might have identified this aberrant anatomy and prevented the injury.

In summary, percutaneous “extra-anatomic” bypass between an excluded bile duct and the bowel for the treatment of bile leakage postsurgery is feasible and might be a viable option when the endoscopic rendezvous technique is not feasible. This approach contributes to restoring continuity while avoiding the necessity for surgical reintervention. Further investigations are warranted to evaluate the safety and efficacy of this technique.

Conflict of Interest

None declared.

Disclosures

The authors have no financial disclosures or competing interests to report.

• References

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• 2 Mutignani M, Bonato G, Dioscoridi L. et al. Expanding endoscopic treatment strategies for pancreatic leaks following pancreato-duodenectomy: a single centre experience. Surg Endosc 2021; 35 (04) 1908-1914
• 3 Standop J, Glowka T, Schmitz V. et al. Operative re-intervention following pancreatic head resection: indications and outcome. J Gastrointest Surg 2009; 13 (08) 1503-1509
• 4 Dzaye O, Erinjeri JP, Kingham TP, Cornelis FH. Internalization of an excluded bile duct after pancreaticoduodenectomy using a percutaneous gun-sight approach. J Vasc Interv Radiol 2023; 34 (07) 1263-1266

Publication History

Article published online:
26 March 2025