In Reply to: Case 1001-05 -- Bile Leak After Diagnostic PTHC and Biliary Biopsy posted by Editor on October 04, 2001 at 12:05:10:
I think that this patient had an obstructive component right from the beginning. I agree, your first cholangiogram shows adequate flow of contrast into the duodenum, but also shows dilation of the CBD.
Probaly the best thing to do in these cases is to leave an internal/external catheter after the biopsy, especially after having placed an 8 F sheath through the transhepatic tract. You really loose nothing with this, it is safe and you can allow time for tract maturation and tube removal if necessary sometime later. In questionable cases like this one, you could leave your access for 6 weeks and bring the patient back for a repeat cholangiogram and re-evaluation. At that point, if cholangiogram is entirely normal you could remove your tube. Another thing that we have done in questionable cases is to place a catheter in the intrahepatic ducts and keep the catheter closed for 2 weeks, in theory to force internal drainage. These 2 weeks are valuable, because if the patient does not tolerate it, he will come back with abdominal pain, fever or even bile leak through the tract. This is a nice, practical clinical test to decide if you need internal external access or if you are OK removing the tube. If after this period of time the patient has had no clinical problems, we repeat LFT's and we perform a cholangiogram. If everything looks good, we then remove the tube. Even another alternative would be to do a biliary Whitaker test, but I do not have any experience with it. Dr Savader has published his experience with this test in JVIR (I do not remember the issue, but it is recent).
Plugging your tract with gelfoam may have helped, however, my rule in these cases is that if any intervention is performed, I leave a tube into the biliary system to preserve access. I think this is a safer approach/.