Complex biliary intervention: Percutaneous small bowel access confirmation with cone-beam computed tomography and retrograde biliary obstruction recanalization

BACKGROUND: To describe our experience with percutaneous small bowel access in patients with surgically altered anatomy for complex biliary intervention where cone-beam computed tomography (CBCT) was used to confirm appropriate small bowel access. METHODS: Retrospective chart review from January 2012 to February 2016 identified 9 patients who underwent complex biliary procedures, which used CBCT assistance. Inclusion criteria were creation of percutaneous small bowel access, usage of CBCT, and biliary recanalization. Procedures were performed using percutaneous small bowel access to assist with antegrade or retrograde biliary recanalization using a variety of wire and catheter techniques. Non-contrast CBCT was used in all cases to confirm appropriate small bowel access. RESULTS: In three patients with disconnected biliary systems and failed prior attempts at percutaneous recanalization, new bilio-enteric anastomoses were successfully created. In 6 patients with prior hepaticojejunostomy and biliary obstructions, percutaneous jejunostomy was used successfully to recanalize the biliary stenoses and place multiple internal biliary stents, which were then managed with percutaneous retrograde exchanges. Five patients are catheter free; two are currently managed with long-term biliary drainage. One patient eventually required liver transplantation and another required surgical revision of anastomotic restenosis. There was a single major complication in one patient where the jejunostomy tube resulted in small bowel obstruction requiring surgical revision. A minor complication occurred in another patient, with the development of cellulitis around the jejunostomy tube. CONCLUSION: CBCT can effectively confirm appropriate percutaneous small bowel access in patients with surgically altered anatomy, and who require retrograde biliary recanalization. CBCT is also useful to guide percutaneous creation of new bilio-enteric anastomosis in patients with disconnected biliary systems.

Evaluación del manejo interdisciplinario de una serie de 53 pacientes con hepatolitiasis / Evaluation of interdisciplinary care of a series of 53 patients with hepatholithiasis

Objetivos: Evaluar, en una serie de enfermos con hepatolitiasis, el resultado del manejo interdisciplinario. Pacientes y métodos: Durante 8 años se valoraron, en un estudio retrospectivo, 53 pacientes con diagnóstico de hepatolitiasis. Resultados: Se estudiaron 23 hombres (43%) y 30 mujeres con una edad promedio de 50 ± 15 años (25 a 83 años). Predominó el dolor (94%), seguido de ictericia (68%) y fiebre (57%). Según la clasificación de Tsunoda, 6 pacientes eran Tsunoda I, 12 Tsunoda II, 4 Tsunoda III y 5 Tsunoda IV. El compromiso más frecuente fue del lóbulo izquierdo (36%) o bilateral (34%). La colangiografía endoscópica tuvo éxito en el 64% y solo se manejaron 4 pacientes por la vía transparietohepática (2 éxitos). Se operaron 35 pacientes (66%) y lo más frecuente fue la hepatectomía izquierda en 40% (7 con asa subcutánea) seguida por hepaticoyeyunostomía con asa subcutánea (26%). Se realizaron cuatro trasplantes ortotópicos de hígado que evolucionan asintomáticos en pacientes con complicaciones por cirrosis. Las complicaciones postoperatorias tempranas fueron del 40%, la más frecuente la infección del sitio operatorio (14%) y cálculos residuales (9%). La complicación tardía más usual fue la litiasis residual (23%). El 80% de los pacientes operados están asintomáticos comparados con el 72% de los no operados. No hubo mortalidad quirúrgica. Conclusiones: La hepatolitiasis es una entidad con manejos no bien estandarizados, entre ellos, la opción quirúrgica cursa con buenos resultados, mejoría clínica y poca morbimortalidad; con el apoyo interdisciplinario dado la radiología intervencionista y la endoscopia biliar.

Objectives: Evaluate the results of interdisciplinary care in a series of patients with hepatolithiasis. Patients and Methods: A retrospective study of 53 patients with hepatolithiasis who were evaluated over an eight year period. Results: 23 men (43%) and 30 women were studied. The average age was 50 ± 15 years (range: 25-83 years). Pain was the predominant symptom (94%), followed by jaundice (68%) and fever (57%). According to the Tsunoda classification, 6 patients were Tsunoda I, 12 were Tsunoda II, 4 were Tsunoda III, and 5 were Tsunoda IV. Left lobe hepatolithiasis was most frequent (36%), followed by bilateral hepatolithiasis (34%). Endoscopic cholangiography was successful in 64% of patients. Only 4 patients were treated by percutaneous cholangiography, with 2 successes. 35 patients (66%) were operated on. The most frequent surgery was left hepatectomy with subcutaneous loop in 7 patients (40%), followed by hepatojejunostomy with subcutaneous loop (26%). Four orthotopic liver transplantations with good evolution were performed in patients with cirrhotic complications. 40% had early complications. Most frequent were infection of the operative site (14%) and residual stones (9%). The most frequent delayed complication was residual lithiasis (23%). 80% of the patients who underwent surgery were asymptomatic compared with 72% of those who did not undergo surgery. There were no mortalities resulting from surgery. Conclusions: Hepatolithiasis is a disease which does not have a well standardized treatment. Surgery is an alternative with good results, clinical improvement and low morbidity and mortality rates when there is interdisciplinary including interventionist radiology and biliary endoscopy.