University of Alabama at Birmingham Birmingham, AL
Introduction:
A 69-year-old male with a persistent biloma required a multidisciplinary biliary reconstruction procedure.Patient has Stage IV colorectal cancer, metastasis to lung and liver s/p partial hepatectomy 6 months ago.He returned with high-grade bile leak and biloma, underwent ERCP with stent placement. Leak persisted and IR placed stent and percutaneous drain. After 1 month, he returned septic and had left biliary percutaneous stent placement.Left main intrahepatic bile duct was occluded and unable to cross into the common hepatic duct. After extensive discussion between advanced endoscopy and IR, planned a biliary reconstruction procedure with combined IR drain and ERCP with common bile duct stent placement
Case Description/Methods:
IR performed a PTC through the preexisting right and left catheter.There was a complete biliary disruption between CBD and right and left biliary systems with bile duct communicating directly with biloma.IR manipulated two catheters into the biloma.The bile duct was cannulated and contrast injected.Extravasation of contrast leaked into biloma consistent with complete disruption of duct.The duct was explored using the SpyGlass direct visualization system.There was abnormal mucosa with ulceration in the upper third of the main bile duct and a large defect in the bile duct opening into the biloma.Using a spybite forceps, the percutaneously delivered guide wires from right and left systems were grabbed and delivered through the major papilla.IR advanced a 10 French catheter with custom side holes.Contrast showed appropriate opacification of small bowel, CBD and intrahepatic ducts.Post procedure he became septic 2/2 biliary manipulation and received antibiotic. He improved and was discharged home without further outpatient complications
Discussion:
Biloma is a well-circumscribed, extrabiliary collection of bile caused by disruption of the biliary tree by traumatic or iatrogenic causes.Little epidemiological data is available due to its rarity.Bilomas can become infected or impinge surrounding structures with associated morbidity and mortality which are reduced with drainage.Majority of bilomas are managed with percutaneous drainage, but endoscopic interventions play a pivotal role when bile leaks are identified by bridging or providing downstream diverting bile duct drainage.Our case is unique as it provides management options for a persistent biloma with complete disruption of the common bile duct by using a cholangioscope and IR assisted procedure for biliary reconstruction
