Use of Biloma Injection Cholangiography to Facilitate Percutaneous Biliary Drain Placement for Bile Leaks: Predictors of Technical Success and Complication Rates

Purpose Percutaneous biliary drain (PBD) placement is a well-established method for treatment of bile leaks. In the setting of a leak, however, the biliary tree is typically non-dilated, making percutaneous transhepatic cholangiography (PTC) and subsequent PBD placement technically difficult. Injection of an extrahepatic biloma can facilitate PTC if contrast can be forced retrograde into the intrahepatic biliary tree. The purpose of this study was to identify factors predicting technical success in opacifying intrahepatic bile ducts through biloma injection and to report complication rates associated with this technique.

Materials and Methods In this retrospective study, 22 patients (11 male, median age = 57 years) underwent 24 PBD placement procedures involving attempted cholangiography via biloma injection between 2007 and 2016. Medical records were reviewed to determine clinical history and outcomes. Multivariate logistic regression was used to identify variables correlating with successful opacification of intrahepatic bile ducts via extrahepatic biloma injection.

Results Bile leaks were diagnosed on the basis of fluid analysis (n = 9), hepatobiliary iminodiacetic acid (HIDA) scan (n = 7), and intraoperative (n = 4) or percutaneous cholangiography (n = 2). The inciting injury was cholecystectomy (n = 9), partial hepatectomy (n = 6), liver transplant (n = 4), or Whipple procedure (n = 3). PBD placement was attempted a median of 31 days after the inciting injury (range = 3 to 191). After biloma injection, sufficient contrast refluxed into the intrahepatic bile ducts to allow PBD placement in 15 procedures. In the remaining nine procedures, intrahepatic bile ducts were not opacified; conventional PTC using blind passes was successful in six of these procedures. Longer time since inciting injury (p = 0.04) and immunocompetence (p = 0.04) correlated with successful opacification of intrahepatic ducts for PBD placement. No episodes of cholangitis were observed.

Conclusion Extrahepatic biloma injection for cholangiography prior to PBD placement is a safe technique that is more likely to be successful in chronic bilomas in immunocompetent patients, presumably because these factors are associated with mature encapsulation of the biloma, thus allowing the collection to be pressurized.