Percutaneous microcoil embolization of intraperitoneal intrahepatic and extrahepatic biliary fistulas

Background: Persistent intraperitoneal biliary fistulas are associated with significant morbidity and mortality. Percutaneous drainage, stenting, and endoscopic sphincterotomy or embolization of biliary radicals have largely replaced the need for hepatic resection or biliary reconstruction in managing such fistulas. When endoscopy is contraindicated, a previously undescribed technique of percutaneous embolization of intrahepatic and extrahepatic biliary fistula following penetrating liver trauma, and orthotopic liver transplant and its application in three patients, will be discussed. Methods: Embolization procedures were performed by an interventional radiologist. Percutaneous trans-hepatic cholangiography via a standard right-side approach or via tube cholangiography was initially performed and the fistula defined. Coaxial catheter systems were used (5 Fr angiography catheters and Tracker 18 infusion catheters), and were positioned within the biliary tree as close as possible to the origin of the fistula. Embolization was performed using vascular Embolization 28 coils (WA Cook) 2-3 mm x 2 cm coils, straight Hilal 18 embolization coils (WA Cook) 5-7 cm, as well as Gelfoam (Upjohn) 1 mm pellets, and Histoacryl (B. Braun) 0.25-1 mt. Occlusion of the duct was confirmed by a selective intrahepatic cholangiogram. In cases of multiple fistulas several embolizations were performed at subsequent procedures. Follow-up is over 13 months without adverse event. Results: The technique was used in the three cases and was successful in all. A peripheral biliary fistula required embolization twice and two cystic leaks were cured after a single attempt. Conclusions: Percutaneous embolization of biliary fistulas provides a management option in cases where conservative treatment has failed and other techniques are relatively contraindicated. The technique is effective and safe in skilled hands, and avoids major surgery. The long-term effect of microcoils in the biliary tree is unknown.