Successful Biliary Re-Cannulation and Neo-Anastomosis Creation in Complete Bile Duct Occlusion or Disruption Using a Combination of Interventional Radiology and Endoscopy Techniques: A Case Series

Introduction: Total biliary occlusion or high-grade leaks are rare but challenging complications of hepatic-biliary-related surgical interventions. This accounts to failure of endoscopic or IR drainage interventions. Recanalization of the biliary tree in these circumstances is a potential solution and require a multidisciplinary approach. We aimed to report a case series of patients who underwent biliary recanalization or neo- anastomosis by interventional radiology (IR) and endoscopic assistance. Methods: Patients who underwent biliary recanalization procedures over the last 3 years were included in this IRB-approved study of a prospectively collected database. Patients were included if they had non-malignant, post-surgical complete or non-traversable biliary anatomy and percutaneous bilioenteric neo-anastomosis or if a neoduct creation was performed. Basic demographic, procedural data, immediate, and long-term follow-up outcomes were recorded and analyzed (Figure 1). Results: A total of 6 patients (67% female) were included (Table 1). The mean age was 63.8 (10.6). Five patients had total bile duct occlusion while 1 patient had complete bile duct disruption. Re-cannulation of the existing biliary tree was accomplished in 3 patients using a radiofrequency (RF) wire percutaneously with endoscopic guidance (n=1), back end of a Glidewire (n=1), and percutaneous targeting of an occluded bare-metal stent (n=1). Neo-anastomosis creation was accomplished in the other 3 patients using a 22G needle under fluoroscopic guidance (n=1), a 22G needle under endoscopic guidance (n=1), and a rendezvous procedure between IR and endoscopy (n=1). Cholangioscopy was used in 3 patients. Technical success in biliary reconstruction was thus 100%. One major adverse event occurred (post-procedure bacteremia treated with antibiotics). There were no procedure-related deaths. Four of 6 patients no longer required an internal/external biliary drain while 2 patients are progressing toward drain removal. Conclusion: In refractory total bile duct occlusion or disruption, reconstruction of the biliary tree can be successfully performed in a multi-disciplinary approach combining endoscopic and IR techniques, which can be a safer alternative to major surgical revision. A combination of tools from IR and endoscopy are valuable in successful re-cannulation or neo-anastomosis formation. Further studies will shed light on the long-term outcomes. Table 1. - Patient History/Indication Number of prior IR/GI procedures Type of Surgery Type of biliary complication Combination procedure with GI Percutaneous Bowel access Recannulation method Size of initial catheter Procedure related complications Technical success with neo construction Follow up -Duration of internal external biliary drain (months) Internalization of stent Number of procedures Readmission 1 (71 yrs. /Female) PUD (status post open distal gastrectomy, Roux-en-Y GB with rising bilirubin 0 and 0 Hepaticojejunostomy Biliary stricture/ clipped anastomosis Yes (Cholangioscope) Yes (jejunum) Back end glidewire 10 F None Yes 6 No 5 No 2 (78 yrs./ Female) Recurrent choledocholithiasis requiring hepatic jejunostomy 9 years ago 1 and 0 Hepaticojejunostomy Biliary enteric stricture Yes Yes (stomach) RF wire 10 F None Yes 6 No 2 No 3 (60 yrs./Female) AdvancedPancreatic cancer with biliary obstruction 2 and 2 None Occluded SEMS with tumor ingrowth No Yes (duodenum) 22G Chiba needle 12 F None Yes 6 No 2 Unrelated 4 (50 yrs./ Female) Primary tumor: Anal squamous cell carcinoma with hepatic mets 1 and 2 Open central hepatectomy, cholecystectomy, ablation of 2 left lateral lesions Left main duct stricture Yes (Cholangioscope) Yes (duodenum) RF wire 10 F None Yes 4 Yes 4 Unrelated 5 (55yrs/Male) Hepatic NET With rising bilirubin 1 and 3 Right hepatectomy Biliary leak and CBD stricture No Yes (duodenum) 22G Chiba needle 14F None Yes 7 No 6 Unrelated 6 (69 yrs./ Male) Stage IV colon cancer 1 and 3 Partial right hepatectomy Biliary leak with disruption at CBD Yes (Cholangioscope) Yes Glidewire 10 F Infection post procedure treated antibiotics Yes 2 Yes 3 No Figure 1.: RF wire about to be grasped by the endoscope.