CardioVascular and Interventional Radiology

Springer-Verlag New York, LLC. 2004 Published Online: 12 May 2004

Cardiovasc Intervent Radiol (2004) 27:383385 DOI: 10.1007/s00270-003-0220-9

Bile Duct Disruption Following Radiofrequency Ablation: Successful Repair Using a Covered Stent
Philip M. Thompson, Christopher M.B. Hare, William R. Lees
Department of Radiology, Middlesex Hospital, Mortimer Street, London W1N 8AA, U.K.

Abstract
Persistent biliary leaks, whether iatrogenic or secondary to malignancy, often present a difcult management problem. Recent reports have suggested a role for covered metallic stents in this context. We describe the successful use of a covered stent to seal a persistent biliary leak following radiofrequency ablation of colorectal liver metastases. Key words: Radiofrequency ablationBile ductsStents and prosthesesLeakage

Radiofrequency ablation (RFA) has become an increasingly widely used technique for the treatment of metastatic disease in the liver. Given the extensive tissue necrosis which RFA can produce, it would seem logical that bile duct damage may result, particularly following treatment of lesions near the liver hilum. This type of complication is not well documented in the literature, although a recent report describes the development of a large intrahepatic biloma due to a bile leak caused by RFA [1]. Conventional treatment of bile leaks in other circumstances often involves prolonged percutaneous or endoscopic biliary drainage. We describe the successful use of a covered metallic stent to seal a persistent biliary leak following RFA of colorectal liver metastases.

Case Report
A 60-year-old man had undergone multiple treatments with radiofrequency ablation (RFA) for colorectal liver metastases, having originally been diagnosed with Dukes C carcinoma of the rectum 6 years previously. Liver metastases were rst diagnosed 212 years after his initial presentation. Chemotherapy with 5-uorouracil, folinic acid and oxaliplatin produced no response and it was decided to proceed to RFA. Following the fth treatment, he developed obstructive jaundice due to a hilar stricture, and a plastic stent was deployed endoscopically to decompress the biliary tree. A month later, he was readmitted with an abscess in the right lobe, which was drained percutaneously with a 10 Fr pigtail catheter (Meditech/Boston Scientic) under ultrasound guidance. At repeat endoscopy, the hepatic end of the plastic stent was found to lie within the abscess cavity (Fig. 1). No communication between the cavity and the biliary tree could be found, and the stent was removed. Percutaneous transhepatic cholangiography demonstrated a stula between the main duct

conuence and the abscess (Fig. 2). The common bile duct could not be accessed as guidewires preferentially entered the abscess cavity, so an 8 Fr external biliary drainage catheter (Meditech/Boston Scientic) was placed in the left duct system. After 2 weeks of treatment with intravenous antibiotics, a combined radiological/endoscopic procedure was performed to achieve internal bile drainage. This was performed by advancing a guidewire through the biliary drainage catheter into the abscess cavity, catching the tip with a basket introduced endoscopically, and pulling the wire back into the duodenum. A 10 Fr internal/external biliary drainage catheter (Meditech/Boston Scientic) was left in situ, ensuring that no side holes were in direct communication with the abscess cavity, which remained externally drained. At repeat cholangiography 2 months later, a persisting bile leak from the main duct conuence into the previous abscess cavity (now a biloma) was shown. This was now thought unlikely to resolve spontaneously, and it was decided to occlude the leak with a covered metallic stent. The biliary drainage catheter was removed over a straight 0.035-inch guidewire, which was then replaced with a superstiff wire. An 8 mm 6 cm expanded polytetrauoroethylene-uorinated ethylene propylene (ePTFE-FEP)-covered stent with proximal side holes (W.L. Gore & Associates, Flagstaff, Arizona) was deployed across the leakage site. Care was taken to allow side branches to drain via the proximal side holes of the stent. The cystic duct was not covered as its conuence with the common hepatic duct was close to the ampulla. An external safety drain was placed in the left main duct. Tube cholangiography 2 days later conrmed the leak to have been sealed successfully (Fig. 3). Filling of the cystic duct was conrmed and a large gall bladder stone was noted. The external drain was removed and the patient was able to return home shortly afterwards. A follow-up CT scan at 3 months demonstrated the biloma to have resolved (Fig. 4). Shortly afterwards, an episode of gall bladder sepsis required needle aspiration and antibiotic therapy. This was thought more likely to be stone rather than stent related, as the cystic duct had not been covered. At 7 months, there was no evidence of biloma recurrence on ultrasound, although there had been marked metastatic disease progression and echogenic material was noted within the stent lumen. The nature of this material was not established as the patient declined further intervention and died a month later.

Discussion
The role of covered metallic stents in biliary interventional radiology is not yet well established. The use of such stents in the treatment of malignant biliary obstruction remains controversial, and problems with stent migration, reocclusion and cystic duct obstruction have all been reported in the literature [2]. The evidence to date is insufcient to support widespread use of covered stents to palliate pancreatobiliary malignancies. However, one situation in which covered stents probably do have a role is in the management of persistent biliary leaks.

Correspondence to: Christopher M.B. Hare; email: christopher.hare@ uclh.org

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P.M. Thompson et al.: Bile Duct Repair Following RFA

Fig. 1. Contrast-enhanced CT scan showing the tip of an endoscopically placed plastic stent within a perihilar liver abscess. There is right lobe atrophy and left lobe hypertrophy. The left main bile duct is obstructed. Fig. 2. Percutaneous cholangiography via a left duct puncture. There is a guidewire passing into the abscess cavity at the hilum. No communication with the common hepatic duct is visible. There is a percutaneous drain in the abscess, and the endoscopic stent has been removed.

Fig. 3. Tube cholangiogram following stent insertion. There is good drainage of the left duct system, and the bile leak has been successfully sealed. The right-sided ducts are chronically obstructed and have not lled. Fig. 4. Follow-up CT scan showing resolution of the right lobe collection. The covered stent is visible. The left duct system is decompressed.

Iatrogenic biliary injury is well recognized in the context of liver resection and laparoscopic cholecystectomy. The initial treatment of choice in this situation is to decompress the biliary tree either endoscopically or percutaneously in order to allow the leak to seal spontaneously. Persistent bile leaks represent a challenge, and various radiological and endoscopic strategies have been employed [3]. In this context, Blasco et al. [4] report successful percutaneous deployment of a covered metallic stent to seal a left bile duct leak post hepatectomy. Malignant biliary stulae present particular difculties as they tend to persist in the absence of biliary obstruction, often leading to failure of conventional management. Warwick et al. [5] describe successful use of a covered stent to seal a postoperative leak from the common bile duct in a patient with an irresectable cholangiocarcinoma.

In the case presented here, bile duct damage occurred in the context of tissue necrosis caused by RFA and supervening sepsis, although it is debatable to what extent endoscopic stent insertion may have contributed to the development of a leak. Consequent breakdown of the surrounding ducts rendered endoscopic access to the proximal biliary tree impossible. A prolonged trial of percutaneous decompression of the biliary tree proved unsuccessful, leaving few remaining treatment options. As in the two cases cited above, we found that a percutaneously deployed covered stent provided a useful solution, allowing palliation of the patients condition at home without the continued discomfort and inconvenience of external drainage.

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References
1. Shankar S, vanSonnenberg E, Silverman SG, Tuncali K, Morrison PR (2003) Diagnosis and treatment of intrahepatic biloma complicating radiofrequency ablation of hepatic metastases. Am J Roentgenol 181(2): 475 477 2. Bezzi M, Zolovkins A, Cantisani V, Salvatore FM, Rossi M, Farelli F, Rossi P (2002) New ePTFE/FEP-covered stent in the palliative treatment of malignant biliary obstruction. J Vasc Interv Radiol 13(6):581589 3. Oliva VL, Nicolet V, Soulez G, Falardeau M, Dalozi P, Abou Jaoude M,

Carignan L (1997) Bilomas developing after laparoscopic biliary surgery: percutaneous management with embolization of biliary leaks. J Vasc Interv Radiol 8(3):469 473 4. Blasco J, Real I, Montana X, Macho J, Arguis P, Burrel M, Bianchi L, Grande L (2001) Percutaneous repair of an iatrogenic laceration of the left bile duct with a covered stent. J Vasc Interv Radiol 12(9):11121115 5. Warwick RJ, Davidson B, Watkinson A (1999) Successful use of a covered nitinol self-expanding stent to seal a malignant stula of the common bile duct. Clin Radiol 54(6):410 412