Seal the deal, a novel approach to refractory bile leak. I'm happy to present this case on behalf of myself, Avril Guo, Rahul Patel, Jaclyn Florio, Nicholas Herter, Satish Nagula, and Anam Rizvi. These are our disclosures. In the way of background, bile duct injuries are known potential complications of laparoscopic cholecystectomy occurring in about 0.4% of elective and 0.8% of emergent cases. Sphincterotomy and plastic stent placement leads to closure in more than 90% of low-grade and about 50% of high-grade bile leaks. Persistent leak is typically treated with a fully covered, self-expanding metal stent leading to closure in nearly all cases. However, in rare cases, bile leaks are refractory to these treatments. There have been several reports of endoscopic treatment with embolic coils and or embolic fluid, primarily cyanoacrylate. In our case, we performed cystic duct stump embolization. We utilized an embolic fluid, 8% ethylene vinyl alcohol, copolymer dissolved in dimethyl sulfoxide with suspended micronized tantalum powder with a 34 centistokes viscosity. Compared to cyanoacrylate, EVOH has a slower copolymerization rate. This leads to a lower risk of non-target embolization and catheter tip entrapment. We also utilized fiber-detachable embolization coils. These are typically used in the embolization of vascular aneurysms. We used them here to provide a scaffold for EVOH to limit and prevent embolic fluid leakage into the peritoneum or common bile duct. Our patient was a 43-year-old male with diabetes, hypertension, and alcoholic cirrhosis. He presented with jaundice and abdominal pain one week after a laparoscopic cholecystectomy for biliary colic. His CAT scan showed moderate ascites and a perihepatic fluid collection. A perihepatic drain was placed, noting high output of about 2,300 cc per day. The fluid bilirubin was high at greater than 25, consistent with bile leak. In line with standard of care, an ERCP was performed with a sphincterotomy and placement of a 10-french-by-7-centimeter plastic biliary stent. You can see on cholangiogram here extravasation of contrast at the site of the cystic duct stump. Following this procedure, peritoneum's drain output decreased to 50 cc per day, and fortunately soon after, the drain output increased to 1,500 cc per day. This indicated persistent bile leak, and so we performed another ERCP with placement of a 10-millimeter-by-8-centimeter fully covered self-expanding metal stent with two 7-french-by-12-centimeter double pigtail plastic stents for anchoring. The drain output decreased from 1,500 cc per day to 500 to 700 cc, however, this was still quite elevated, indicating persistent leak. A percutaneous transhepatic cholangiogram drain placement was considered but felt to be too high a risk in the setting of decompensated cirrhosis, and so the decision was made to pursue cystic duct stump embolization with the support of our interventional radiology colleagues. This is a video showing removal of the plastic stent that was coaxial with the fully covered self-expanding metal stent. This is now the removal of the fully covered metal stent. You can see here pus draining from the bile duct. From here we perform cholangioscopy with wire placement into the cystic duct stump. Contrast injection was then performed using a 4-fringe catheter with a coaxial 2.8-fringe microcatheter. Here you can see again showing the extravasational contrast from the cystic duct stump. From here a fiber detachable embolization coil deployment was performed. Two coils were deployed into the cystic duct stump. Following this EVOH embolic fluid injection was performed into the embolic coils. Here you can see a blush around the coils where the fluid is being injected. Seen here is the post-embolization cholangiogram with contrast being directly injected into the cystic duct stump with no extravasation of contrast noted. On the right you can see placement of the fully covered self-expanding metal stent with an anchoring double pigtail plastic stent to prevent embolic material dislodgement following embolization. Following this procedure minimal drain output was noted the next day. Fluid bilirubin decreased to 1.9 indicating resolution of bile leak. After discharge the patient had the periopatic drain removed in the outpatient setting and a two-month follow-up and ERCP was performed. Here you can see the occlusion cholangiogram without any notable extravasational contrast. You can still see the embolic material in the cystic duct stump. This indicated resolution of bile leak and a durable bile leak closure. Bile duct stents were removed. This case shows that there is certainly a need for novel endoscopic salvage therapy for refractory bile leaks, particularly in patients with significant comorbidities that limit the feasibility or safety of alternative interventions. Cystic duct stump embolization is a promising minimally invasive therapy that can lead to durable bile leak closure in this population. Embolic material migration leading to CBD obstruction and cholangitis are the primary complications of concern. This risk, however, can be mitigated by placing a covered metal biliary stent immediately following embolization. To conclude, cystic duct stump embolization for refractory bile leaks is technically feasible. Cystic duct stump embolization with fiber detachable coil deployment and EVOH injection appears to result in a durable bile leak closure. Additional studies are needed to assess the safety and efficacy of this novel technique before routine use in practice.

refractory bile leaks

cystic duct stump embolization

ethylene vinyl alcohol

minimally invasive therapy

embolization coils