Sandwich technique for refractory complex bile leak post right hemi-hepatectomy. Biliary leakage may complicate hepatectomy, ranging from 3 to 10 percent of reported cases. Non-surgical management is currently preferred, either through endoscopic, percutaneous, or combination of both. Sandwich technique is well-reported in the endovascular therapy for aneurysms since 2008. We adopted this technique to manage a complex post-hepatectomy bile leak. Our patient is a 42-year-old female, diagnosed case of tetanal neuroendocrine tumor with liver metastasis, status post Y90 treatment, and extended right hemi-hepatectomy and small bowel resection in 2016. This was complicated by saphrenic abscess and recurrent bile leak with bilioplural and biliocutaneous fistula. She subsequently underwent right lung lower lobectomy with creation of thoracic window in 2017, and combined endoscopic retroglucal angiography with insertion of biliary-covered stems and PTC catheters in segments 2 and 3 in 2018. Despite multiple interventions, there was persistence of a large volume bile leak from the biliocutaneous fistula with a large and complex skin opening, causing irritant contact dermatitis, and poor quality of life. She was then offered sandwich technique stenting. What is sandwich technique? It is a parallel stent graft approach for aneurysm repair, involving multi-vessels, such as toraco-abdominal or aorto-iliac. It involves placing multi-stents within a graft to allow continuous blood flow. Our patient will benefit from this technique by allowing continuous downstream bile flow and expectantly sealing the leak, and improving quality of life. On the right bottom figure is a cross-sectional representation of segment 2 and 3 stents within the biliary-covered stems. The major papilla was seen with the segment 2 PTC stent inside too. The distal portion of the previously inserted covered stems could not be seen due to overgrowth. Initial cholangiogram showed leak at the main left hepatic duct with no downstream outflow of contrast into the existing biliary-covered stems. The spiglas was advanced percutaneously through the segment 2 duct. Cholangioscopy mapping was started at the junction of the existing biliary-covered stems to identify the healthy and diseased segment to facilitate sandwich technique stenting. A large defect in the main left hepatic duct, which led to the bilial pleural fistula, was identified. The landing point between the healthy and diseased segment at segment 2 was seen. Feeling defects were seen within the biliary-fully covered stems. Large amount of sludge were removed with extraction balloon catheter. An extraction balloon was inflated to 15 millimeter and the existing covered stems was adjusted to an ideal position just below the leak to facilitate sandwich technique stenting. A spiglas-directed guide wire insertion into the covered stems was performed, and this was further advanced into the duodenum. Sequential dilation of segments 2 and 3 were performed for easier insertion of biliary-covered stems. The extraction balloon was inflated at the mid-portion of existing covered stems as counter-traction as the 6x60 biliary-covered stems were simultaneously deployed in the segments 2 and 3. This is to avoid dislodging the existing covered stems inferiorly. Simultaneous dilation with 6x40 millimeter balloon to get an adequate wall apposition of the newly inserted covered stems in segments 2 and 3. Deployment of a new 10x60 millimeter covered stems at the distal CBD was performed due to overgrowth. And finally, good flow of contrast through the segments 2 and 3 stems into the biliary-covered stems and into the duodenum. No evidence of leak in the main left hepatic duct. Pre-procedure, change of dressing was performed twice a day with 10 gauze and 1 ganchi pad, and these were fully soaked. After the procedure, twice a day change of dressing was still performed with same amount of gauze usage with improvement in terms of mild to moderate soaked dressing, and mostly these were serious stain. Hopefully, this will help seal the leak and improve her quality of life. To our knowledge, this is the first biliary case of the sandwich technique reported, and it may be offered as an alternative modality of treatment in the management of a complex bile leak. The role of combined endoscopic retrograde cholangiography and PTC is essential in the success of this procedure. Percutaneous cholangioscopy is important in assessing the ideal landing point to help reach the healthy and diseased segment of the duct to facilitate sandwich technique stenting. Multidisciplinary approach and teamwork is key for success and optimal management of these patients.

sandwich technique

refractory complex bile leak

right hemi-hepatectomy

biliary leakage

non-surgical management