Molloy Making Connections 05012016

8/18/2019 Molloy Making Connections 05012016

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MAKING CONNECTIONS

Resident: Chris Molloy, MD

Fellow: Christian Coroian, MD, MBA

Attending: Tina Hardley, MD

Program/Dept(s): Los Angeles Medical Center

Los Angeles Medical Center


2/28

Chief Complaint 36 year old male status post right hepatectomy with persistent biloma

refractory to percutaneous biliary drain, now with high volume cloudybiliary drain output, shakes, rigors and RUQ pain

History of Present Illness En bloc right hepatectomy for large parenchymal echinococcal cyst

causing biliary compression and pancreatitis. Post operativelycomplicated by complicated biloma with persistent biliary drainagethrough percutaneous biliary drain which continued four weekspostoperatively

Grew up on a farm in India with countless dogs and cattle

CHIEF COMPLAINT & HPI


3/28

RELEVANT HISTORY

Past Medical History Recent pancreatitis and obstructive jaundice, ERCP with sphincterotomy,

balloon dilatation of biliary ducts and biliary stent

Past Surgical History

Recent right sided en block hepatectomy for large echinococcal cyst withpersistent bile leak, resultant biloma formation and obstructive biliarystenosis

Family History

Mother with diabetes and hypertension

Review of Systems

Positive for nausea, vomiting, fevers, rigors, and RUQ abdominal pain


4/28

RELEVANT HISTORY

Medications Albendazole

Ciprofloxacin

Ondansetron

Enoxaparin

Allergies No known drug allergies


5/28

DIAGNOSTIC WORKUP

Physical Exam A&Ox3, NAD, abdomen soft, mildly tender to pressure, right sided drain intactwith no sign of infection or erythema

Vitals BP 108/70 | Pulse 87 | Temp 97.2 °F | Wt 51.8 kg

Laboratory Data

T.Bili 1.0 / ALT 76 / Alk Phos 319

Albumin 3.4 / Prealbumin 26

INR 1.3

6.2

10.2

31.6

248 0.74

136

3.7

104

26

15


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DIAGNOSTIC WORKUP

Original pre-surgical 3 phase liver CT (axial view) demonstrating 7.8cm complex cystic masswithin the right lobe of the liver


7/28

DIAGNOSTIC WORKUP

Original pre-surgical 3 phase liver CT (coronal view) demonstrating a multilobulated 7.8cm

complex cystic mass within the right lobe of the liver. At this time there was also biliary

dilatation, and splenomegaly.


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DIAGNOSTIC WORKUP

Gross Pathology of Echinococcal Cyst after en-bloc right hepatectomy


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DIAGNOSTIC WORKUP

One week after the right hepatectomy CT abdomen (axial and

coronal view) revealed a large fluid collection within the

surgical bed. A right sided 16f percutaneous biliary drain was

subsequently placed to drain biloma secondary to persistent

bile leak


10/28

Follow up CT abdomen (coronal and axial views) aft

sided percutaneous drain (blue arrow) was placed w

biloma demonstrating decreased fluid collection (gree

however his symptoms continued.

INTERVENTION: BILIARY DRAINAGE


11/28

MRCP 3D reformat demonstrates complete obstruction of the left hepatic biliary duct (green arrow

There was no communication between the left biliary duct (green arrow), the right biliary tube/bilom(black arrow) or the common bile duct (blue arrow). The duodenum is also seen (purple arrow).

DIAGNOSTIC WORKUP

Resected right lobe

Biloma


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Percutaneous attempt to connectfrom the right externaldrain/biloma to the CBD wasunsuccessful, as no directconnection was visualized

Note: left biliary tube access wasadvanced into the biloma, butfurther extending the left sidedconnection into the CBD provedunsuccessful

INTERVENTION: PERCUTANEOUSCHOLANGIOGRAM

Cholangiogram demonstrated no direct con

between the biloma /right percutaneous pigt

arrow) and the CBD and/or the left biliary sPercutaneous left biliary tube (green arrow) is a


13/28

GI Endoscope (purple arrow) demonstrating no direct connection between

the CBD (blue arrow) and right external drain/biloma (black arrow). The leftpercutaneous biliary drain (green arrow) is also seen.

INTERVENTION: ERCP

•

GI unsuccessfully attempteto connect the CBD to theright external drain/bilomaand then attempted toconnect the CBD to the leftbiliary system

• The ERCP approach wasunsuccessful due tosuboptimal indirect anglesbetween the access sites anthe CBD


14/28

Combined rendezvous procedure was planned with IR & GIcollaboration to establish a connection from the remaining leftbiliary system through the biloma to the CBD

INTERVENTION: RENDEZVOUS

Resected right lobe

Biloma


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The occluded ends of the lefthepatic duct and the CBD wereoriented obliquely and severalattempts to recanalize thisconnection were made from theendoscopic approach wereunsuccessful

IR attempted to recanalize from theleft duct, however due to theoblique orientations and lack ofproximity this was also unsuccessful


Rendezvous procedure with GI Endoscopic a

(purple arrow) in the CBD (blue arrow), the

percutaneous biliary drain/biloma (black arleft percutaneous biliary drain (green arro


16/28


• Through the right percutaneousdrain, a metal transjugular biopsycannula was used with the back endof an Amplatz wire to direct sharprecanalization from the right biliaryaccess/biloma to the CBD.

• Subsequently a wire from the left

duct access was also advanced intothe CBD

Rendezvous procedure with Amplatz wire (black arrow) recanalizing a

to the CBD (blue arrow), with simultaneous GI Endoscopic access (puarrow). The left percutaneous biliary access is also seen (green arrow

Resected right lobe

Biloma


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• Once access to the CBDwas confirmed, a markerpigtail catheter (with hubcut off) was loaded ontothe Amplatz wire in reverse

and advanced into the CBD• Then the pigtail catheter

was snared endoscopicallyand retracted until thepigtail formed in the biloma

Rendezvous procedure with pigtail (black arrow) f

right access into the CBD (blue arrow), snared v

endoscope. The left percutaneous biliary access arrow) is also seen with wire extending into the


18/28


•

A 7F reinforced Anselsheath advancedthrough the left ductaccess into the biloma.

• A 15mm goosenecksnare was introduced

and the pigtail wassnared and withdrawnout the skin throughthe left biliary ductaccess.

Rendezvous procedure with pigtail (black arrow) from the

percutaneous access with the tip in the CBD . Snare introd

from the left percutaneous biliary access (green arrow


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Resected right lobe

“Rendezvous Procedure” Internal-External Connection

Reverse pigtail coiled in the biloma is snared from the left percutaneous biliary access and

retracted out the left biliary access site to complete the three-way connection from the 1)

left biliary system, 2) to the biloma and 3) internally through the CBD to the duodenum

Biloma


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• The pigtail was snared andretracted out the left access toestablish a platform to place aconventional left internalexternal biliary tube

• The pigtail was then advancedto the ligament of Treitz over anAmplatz wire and the tract wasserially dilated to 14F

• Customized internal externalbiliary drain with extra sideholes at the level of the bilomawas positioned from left accessthrough the biloma through the

CBD and into the duodenum

Rendezvous procedure: customized internal external drainage

pigtail (black arrow) now in duodenum, extending through th

through the left biliary system(green arrow) and exiting percu


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• Completion cholangiogram withinternal external left biliarysystem to biloma to CBD toduodenum drain which re-established communication of theleft intrahepatic ductal system to

the CBD• Percutaneous right biloma drain

with cope loop

Rendezvous procedure: internal-external biliary drain with pig

arrow) in duodenum, extends through biloma (black arrow) &

percutaneous access(green arrow). Right percutaneous drain

Resected right lobe

Biloma

Duodenum

Left externaldrain


22/28


Cholangiogram: internal-external biliary drain with pigtail (blac

duodenum, extends through CBD and exits the left percutaneo

(green arrow). Right percutaneous drain is also seen (blue

• 10 days post procedure,cholangiogramdemonstrates completedecompression of the priorbiloma and patent biliarydrainage to the duodenum

• The right biloma drain wasremoved at this time


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QUESTION SLIDE

What are the indications for percutaneous biliary drainageA. To perform portal vein thrombectomy

B. To gain hepatic artery access

C. To decompress obstructed biliary tree

D. To remove the gallbladder


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CORRECT!

Answer C: decompress an obstructed biliary tree is one appropriate indication for

percutaneous biliary drainage. Percutaneous biliary drainage is not used for portal veinthrombectomy, hepatic artery access or gallbladder removal. Additional indications forpercutaneous biliary drainage are listed below.

Indications for percutaneous biliary drainage

Provide adequate biliary drainage or decompress obstructed biliary tree

Divert bile from and place stent in bile duct defect

Provide access to the biliary tract for therapeuty including:

Dilate biliary strictures

Remove bile duct stones

Stent malignant lesions

Brachytherapy

Endoluminal tissue sample or foreign body retrieval

Provide a portal of access to the biliary tract for mid- to long-term diagnostic purposes

Wael E. A. Saad, MD, Michael J. Wallace, MD, Joan C. Wojak, MD, Sanjoy Kundu, MD, and John F. Cardella, MD

Improvement Guidelines for Percutaneous Transhepatic Cholangiography, Biliary Drainage, and Percutane

Cholecystostomy, J Vasc Interv Radiol 2010; 21:789 –

795

Return to


25/28

SORRY, THAT’S INCORRECT

Answer C: decompress an obstructed biliary tree is one appropriate indication for

percutaneous biliary drainage. Percutaneous biliary drainage is not used for portal veinthrombectomy, hepatic artery access or gallbladder removal. Additional indications forpercutaneous biliary drainage are listed below.

Indications for percutaneous biliary drainage

Provide adequate biliary drainage or decompress obstructed biliary tree

Divert bile from and place stent in bile duct defect

Provide access to the biliary tract for therapeuty including:

Dilate biliary strictures

Remove bile duct stones

Stent malignant lesions

Brachytherapy

Endoluminal tissue sample or foreign body retrieval

Provide a portal of access to the biliary tract for mid- to long-term diagnostic purposes

Wael E. A. Saad, MD, Michael J. Wallace, MD, Joan C. Wojak, MD, Sanjoy Kundu, MD, and John F. Cardella, MD

Improvement Guidelines for Percutaneous Transhepatic Cholangiography, Biliary Drainage, and Percutane

Cholecystostomy, J Vasc Interv Radiol 2010; 21:789 –

795

Return to


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• Biliary stricture classification

•Type I: > 2 cm distal to the hepatic confluence

• Type II: within 2 cm from hepatic confluence

• Type III: involve a patent confluence

• Type IV: involve and obstruct the confluence

• Type V: involve the hepatic duct associated with stricture on aberrant intrahepaticbranch

TEACHING POINT

Alampady Krishna Prasad Shanbhogue, Sree Harsha Tirumani, Srinivasa R. Prasad, Najla Fasih, and Matthew MBenign Biliary Strictures: A Current Comprehensive Clinical and Imaging Review, AJR online, AJR 2011; 197:W2


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FOLLOW-UP

After 10 days, follow-upcholangiogram demonstratedcomplete decompression of the bilomaand the right biliary drain was removed

The internal-external drain has beencapped and the patient is now

asymptomatic after the successfulplacement of a left internal-externalbiliary drain

Cholangiogram: internal-external biliary d

with pigtail in duodenum, extending throu

CBD, through the biloma and exiting the lpercutaneous access.

Prior biloma

Duodenum

Left external drain


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REFERENCES

Wael E. A. Saad, MD, Michael J. Wallace, MD, Joan C. Wojak, MD, Sanjoy Kundu, MD, and John F. CaQuality Improvement Guidelines for PercutaneousTranshepatic Cholangiography, Biliary Drainage,Percutaneous Cholecystostomy, J Vasc Interv Radiol 2010; 21:789 –795

Alampady Krishna Prasad Shanbhogue, Sree HarshaTirumani, Srinivasa R. Prasad, Najla Fasih, andMcInnes, Benign Biliary Strictures: A Current Comprehensive Clinical and Imaging Review, AJR onlin197:W295–W306

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Molloy Making Connections 05012016