molloy making connections 05012016
TRANSCRIPT
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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
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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
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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
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RELEVANT HISTORY
Medications Albendazole
Ciprofloxacin
Ondansetron
Enoxaparin
Allergies No known drug allergies
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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
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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
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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
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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
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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
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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
INTERVENTION: RENDEZVOUS
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
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INTERVENTION: RENDEZVOUS
• 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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INTERVENTION: RENDEZVOUS
• 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
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INTERVENTION: RENDEZVOUS
•
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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INTERVENTION: RENDEZVOUS
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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INTERVENTION: RENDEZVOUS
• 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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INTERVENTION: RENDEZVOUS
• 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
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INTERVENTION: RENDEZVOUS
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
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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