Abstract
Acute cholecystitis is a common inflammatory condition of the gallbladder, primarily associated with gallstones. Complications such as bile duct injury and bile leakage can occur following cholecystectomy, significantly impacting morbidity and mortality. Early diagnosis and intervention are essential to improve patient outcomes, with treatment options including endoscopic sphincterotomy and stenting. However, percutaneous coil embolization has emerged as a critical intervention due to the anatomical complexity of the region.
Keywords: Cystic duct injury, Bile leakage, Coil embolization, Interventional radiology
Introduction
Acute cholecystitis is an acute inflammation of the gallbladder, most commonly associated with gallstones (90-95%). Gallstones typically cause obstruction at the neck of the gallbladder or the cystic duct, leading to distension and bile stasis within the gallbladder. This condition subsequently triggers inflammatory processes due to bacterial colonization. Acute cholecystitis develops without gallstones in 5%-10% of cases, a condition known as acalculous cholecystitis. Clinically, acute cholecystitis usually presents with right upper quadrant pain, which is often accompanied by fever, nausea, vomiting, fatigue, and anorexia [1,2].
Laparoscopic cholecystectomy is currently the most commonly and primarily preferred minimally invasive surgical method for the treatment of various biliary conditions, including acute and chronic cholecystitis, biliary colic, gallstone pancreatitis, and biliary dyskinesia [3]. Bile duct injury and bile leakage following cholecystectomy are rare but serious complications that increase mortality and morbidity. Early diagnosis and management are crucial for the patient's prognosis. While treatment options such as endoscopic sphincterotomy and stenting are available, the anatomical complexity of the region has led to the increasing importance and frequency of percutaneous coil embolization in recent times [4,5].
In this study, we present a case of percutaneous transcatheter coil embolization in a patient who developed bile duct leakage following cholecystectomy.
Case presentation
A 65-year-old male patient, with no known history of surgical or systemic disease, presented to the emergency department with severe pain in the right upper quadrant and epigastric region. On physical examination, the Murphy sign was found to be positive. Laboratory investigations revealed an elevated white blood cell count of 27,760 cells/mL (Normal range [N]: 4500-10,000 cells/mL), which was notably high. Based on the clinical and laboratory findings, acute cholecystitis was considered the primary diagnosis. Further evaluation of the hepatobiliary system was conducted using abdominal ultrasonography (USG) and contrast-enhanced abdominopelvic computed tomography (CT). The USG findings demonstrated that the gallbladder was hydropic with mild thickening of the gallbladder wall, and no significant stones or sludge were detected within the gallbladder lumen. Similarly, contrast-enhanced abdominopelvic CT findings did not reveal any significant stones or sludge within the gallbladder lumen; however, the gallbladder's transverse diameter was measured at 45 mm (Normal range [N]: < 40 mm), indicating an increase in wall thickness. Additionally, pericholecystic fat stranding and free fluid accumulation with inflammation were observed (Fig. 1). These findings were supportive of a diagnosis of acalculous cholecystitis, and the patient subsequently underwent laparoscopic cholecystectomy.
Fig. 1.
In the contrast-enhanced abdominopelvic CT imaging, axial (A) and coronal (B) sections demonstrate a hydropic gallbladder (white arrows) and free fluid associated with heterogeneous density increases consistent with an inflammatory process in the pericholecystic region (white arrowheads).
On the fifth day following laparoscopic cholecystectomy, the patient developed widespread abdominal pain, defense, rebound tenderness, and fever. The presence of significant bile content in the drainage catheter, which had been intraoperatively placed in the surgical site, raised suspicion of a common bile duct injury, and the patient was consulted to the Interventional Radiology (IR) unit. A percutaneous transhepatic cholangiography (PTC) was performed in the IR unit, revealing no intrahepatic bile duct dilatation, and the common bile duct was found to be patent. However, retrograde filling of the cystic duct stump into the subhepatic space and the drainage pouch was observed, indicating an injury to the cystic duct stump. Based on these findings, a percutaneous internal-external biliary drainage catheter was placed, and catheter monitoring was performed (Fig. 2). Four days later, the patient was re-evaluated in the IR unit, and a 4F cobra catheter and microcatheter were inserted via the guidewire through the internal-external biliary drainage catheter. Following catheterization, coil embolization was performed on the cystic duct stump. Follow-up imaging revealed no passage of contrast material into the cystic duct (Fig. 3).
Fig. 2.
illustrates a percutaneous transhepatic cholangiography examination. The image shows a percutaneous drainage catheter (white arrowheads) and a percutaneous internal-external biliary drainage catheter (white arrows). Additionally, retrograde contrast filling of the cystic duct and contrast flow towards the drainage bag are observed (white circle).
Fig. 3.
Control cholangiography reveals retrograde bile leakage from the cystic duct stump (A). The cystic duct stump was catheterized using a 4F cobra catheter and microcatheter, followed by coil embolization (B and C white arrows). The control cholangiography demonstrated no passage into the cystic duct (D).
Discussion
Bile leakage can occur as a result of surgical, endoscopic, and radiological procedures, but also due to other factors such as trauma, congenital diseases, and infections [4]. Postlaparoscopic cholecystectomy bile leakage is observed in 0.2%-2% of cases and is recognized as a serious complication that, if not treated promptly, prolongs hospital stays and increases morbidity and mortality rates. The cystic duct stump is the most common site of bile leakage, occurring in 94.5% of cases [5]. Although biliary diversion, endoscopic sphincterotomy, and/or stenting are initially preferred treatment options, these methods fail in 25% of cases. However, spontaneous resolution of bile leakage has been reported in many instances. In patients with bile leakage, percutaneous drainage for biliary decompression can achieve clinical success; however, prolonged catheterization and extended hospitalization may negatively impact the prognosis. In cases where endoscopic and percutaneous treatments are inadequate, persistent bile leakage can lead to subhepatic/subphrenic abscesses, bilomas, biliary peritonitis, biliary stricture and other serious complications. Therefore, rapid and effective identification and closure of the leakage source is crucial [6].
In cases where endoscopic and percutaneous treatments are inadequate following bile leakage, transcatheter embolization emerges as a frequently preferred treatment method. To seal bile leaks, various agents such as ethanol, N-butyl cyanoacrylate (glue), ethylene-vinyl alcohol copolymer (Onyx), vascular occluders, and occlusion balloons can be utilized in embolization therapy [6,7].
Percutaneous coil embolization is one of the most commonly used techniques following bile leakage. The minimally invasive nature of this method, along with its applicability under mild sedation and local anesthesia, stands out as a significant advantage. Performing coil embolization through an existing percutaneous biliary drainage catheter without the need for a new entry site reduces the risks of infection, bleeding, and pain. Coil migration is a rare complication of coil embolization that can lead to bile duct obstruction and recurrence of bile leakage [7,8].
Conclusion
Bile leakage following cholecystectomy, although rare, is a serious complication that can adversely affect the prognosis. A multidisciplinary approach involving surgeons, gastroenterologists, and interventional radiologists plays a critical role in early diagnosis and effective treatment. Transcatheter coil embolization is a reliable, effective, and feasible treatment method that can effectively seal bile leaks, reducing the need for surgical and endoscopic interventions in selected patient populations.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Author contributions
Furkan Özdem: Conception, design, literatüre review, supervision, critical review, writer.
Patient consent
Informed consent was obtained from all individual participants included in this study.
Footnotes
Competing Interests: Furkan Özdem has read and approved the manuscript, and, subject to acceptance, authors will transfer copyright to the Publisher; there is no ethical problem or conflict of interest, and there has been no duplicate publication or submission elsewhere.
References
- 1.Kimura Y., Takada T., Kawarada Y., Nimura Y., Hirata K., Sekimoto M., et al. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepato-Biliary-Pancreatic Surg. 2007;14:15–26. doi: 10.1007/s00534-006-1152-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Gallaher J.R., Charles A. Acute cholecystitis: a review. JAMA. 2022;327(10):965–975. doi: 10.1001/jama.2022.2350. [DOI] [PubMed] [Google Scholar]
- 3.Litwin D.E., Cahan M.A. Laparoscopic cholecystectomy. Surg Clin North Am. 2008;88(6):1295–1313. doi: 10.1016/j.suc.2008.07.005. [DOI] [PubMed] [Google Scholar]
- 4.Schmitz D., Mutignani M., Neumann U.P., Wielpütz M.O., Hagenmüller F., Rudi J., et al. Percutaneous embolization of biliary leaks: a systematic interdisciplinary review and proposal for a new classification. Digest Dis Intervent. 2020;4(02):214–222. [Google Scholar]
- 5.Salsano G., Paparo F., Valdata A., Patrone L., Filauro M., Rollandi G.A., et al. Management of bile leak from Luschka ducts after laparoscopic cholecystectomy: an original procedure for coil embolization. Cardiovasc Intervent Radiol. 2016;39:483–486. doi: 10.1007/s00270-015-1220-2. [DOI] [PubMed] [Google Scholar]
- 6.Uyanik S.A., Atli E., Oguslu U., Cevik H., Yilmaz B., Gumus B. Percutaneous treatment of postoperative bile leaks with coil embolization after cholecystectomy. Eurasian J Med Invest. 2021;5:45–50. [Google Scholar]
- 7.Massoumi H., Kiyici N., Hertan H. Bile leak after laparoscopic cholecystectomy. J Clin Gastroenterol. 2007;41(3):301–305. doi: 10.1097/MCG.0b013e31802c29f2. [DOI] [PubMed] [Google Scholar]
- 8.Nezami N., Jarmakani H., Arici M., Latich I., Mojibian H., Ayyagari R.R., et al. Selective trans-catheter coil embolization of cystic duct stump in post-cholecystectomy bile leak. Digest Dis Sci. 2019;64:3314–3320. doi: 10.1007/s10620-019-05677-5. [DOI] [PubMed] [Google Scholar]