Post-operative complications following hepatobiliary surgery: imaging findings and current radiological treatment options Poster No.: C-1501 Congress: ECR 2015 Type: Educational Exhibit Authors: A. Hadjivassiliou, D. Bosanac, D. Yu; London/UK Keywords: Embolisation, Cholangiography, Ultrasound, Fluoroscopy, CT, Interventional non-vascular, Gastrointestinal tract, Biliary Tract / Gallbladder, Transplantation DOI: 10.1594/ecr2015/C-1501 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 18
Learning objectives To view cases of post operative complications following hepatobiliary surgery (including liver resection, pancreaticoduodenectomy, liver transplantation and laparoscopic cholecystectomy) on different imaging modalities Present examples of treatment options performed by interventional radiologists Page 2 of 18
Background Post operative complications following hepatobiliary surgery are frequently encountered in the clinical setting Some complications can be managed conservatively while others require interventional treatment Early recognition of such complications is essential for optimising patient care Interventional radiology has revolutionised the post-operative management of these critically ill patients Page 3 of 18
Findings and procedure details Our institution is a tertiary referral centre for hepatobiliary diseases. We present a series of cases with post-operative complications following hepatobiliary surgery such as liver resection, pancreaticoduodenectomy, liver transplantation and laparoscopic cholecystectomy. LIVER RESECTION Indications: Primary malignancy: HCC, cholangiocarcinoma Secondary malignancy: colorectal metastases Benign timours: hepatic adenoma, biliary cystadenoma Infective causes: hydatid cyst, liver abscess, recurrent cholangitis Traumatic: accidental, iatrogenic The normal liver segmental anatomy is demonstrated in Figures 1 and 2. There are different types of liver resection which include: Wedge resection Left lateral segmentectomy (segments II/III) Left hepatectomy (segments I-IV) Extended left hepatectomy (left trisegmentectomy, segments I-IV, V-VIII) Right hepatectomy (segments V-VIII) Extended right hepatectomy (right trisegmentectomy, segments IV-VIII) Central resection (segments IV, V and VIII) Non-anatomical resection Modified extended left hepatectomy Modified extended right hepatectomy Caudate resection +/- caval reconstruction Complications: Hepatic artery occlusion/stenosis/pseudoaneurysm Bile leak/anastomotic stricture Haemorrhage Collections Figures 3-9 demonstrate examples of these complications. Page 4 of 18
PANCREATICODUODENECTOMY Two different types of pancreaticoduodenectomy are currently performed; conventional and pylorus preserving pancreaticoduodenectomy. The conventional type includes distal gastrectomy, removal of pancreatic head, duodenum, proximal jejunum, common bile duct and gallbladder. The pylorus preserving variant preserves the gastric antrum, pylorus and proximal duodenum which is subsequently anastomosed onto the jejunum. Indications: Pancreatic malignancy Ampullary carcinoma Distal cholangiocarcinoma Duodenal carcinoma Benign periampullary neoplasms not suitable for ampullectomy Complications: Portal vein stenosis Bile leak/anastomotic stricture Post-operative delayed haemorrhage Collections An example of a post-operative collection is illustrated in Figure 9. LIVER TRANSPLANTATION Indications: Acute fulminant liver failure Chronic hepatitis B or C Alcoholic liver disease Haemochromatosis Primary sclerosing cholangitis Primary biliary cirrhosis Malignancy, most commonly hepatocellular carcinoma Liver transplant anatomy includes arterial anastomosis, portal venous anastomosis, IVC anastomosis and biliary anastomosis. Complications: Page 5 of 18
Transplant hepatic artery stenosis/anastomotic stricture Pseudoaneurysm Haemorrhage Transplant portal vein thrombosis/anastomotic stenosis Anastomotic IVC stenosis Kinking of hepatic vein Budd Chiari Bile leak Biliary anastomotic and non-anastomotic strictures Calculus Collections Examples of complications are shown in Figures 10-17. LAPAROSCOPIC CHOLECYSTECTOMY Laparoscopic cholecystectomy is currently the preferred surgical option for gallbladder removal. Complications: Bile duct injury Bile leak Calculus retention Haemorrhage Malpositioned/spilled surgical clips Trocar injury Collections An example of a malpositioned clip on the common bile duct is demonstrated in Figure 18. Page 6 of 18
Images for this section: Fig. 1: Liver segment anatomy as per the Couinaud system. This separates the liver into eight segments with each one having its inflow and outflow blood supply as well as its own biliary drainage. http://www.radiologyassistant.nl/en/p4375bb8dc241d/anatomy-of-the-liversegments.html Fig. 2: Liver segmental anatomy on contrast enhanced CT. Page 7 of 18
Fig. 3: Bilomas in sites of previous non-anatomical resection for multifocal hepatocellular carcinoma demonstrated on (a) CT, (b) US and (c) MRI. Fig. 4: Same patient as in Figure 3 following resection. (a) Endoscopic retrograde cholangiopancreatography (ERCP) demonstrates biliary leak and endoscopic stent subsequently inserted. (b) Persistent leak despite endoscopic stent demonstrated on cholangiography therefore left internal/external drain inserted. This still did not control the leak. (c) Right percutaneous transhepatic cholangiogram (PTC) confirms continued leak and right internal external drain was then inserted. (d) Internal/external drains internalised with Carey-Coons stents. (e) Follow up CT shows decrease in size of collections and stents removed. Page 8 of 18
Fig. 5: Contrast enhanced axial CT post extended left hepatectomy illustrating a gas containing collection adjacent to the liver cut-surface (a, b). Pig tail drain inserted drained the collection successfully with decrease in size on follow up study (c). Fig. 6: Same patient as in Figure 5 post extended left hepatectomy. Evidence of pseudoaneurysm formation on axial CT most likely secondary to previous bile leak (a). Angiography confirmed presence of hepatic artery pseudoaneurysm (b). Fig. 7: Same patient as in Figures 5 and 6 post extended left hepatectomy. Interval increase in size of pseudoaneurysm despite previous coiling as demonstrated on arterial phase axial CT (a) and angiography (b). Stent was subsequently inserted in the hepatic artery which controlled the bleed successfully (c). Page 9 of 18
Fig. 8: Angiogram following extended right hepatectomy demonstrates abrupt cut off of contrast in keeping with hepatic artery occlusion which was managed conservatively. (b) The patient subsequently developed liver abscesses. (c) A pigtail drain was inserted followed by complete resolution of the hepatic abscesses on follow up imaging. Fig. 9: (a) Patient post right hepatectomy and pancreaticoduodenectomy. Axial contrast enhanced CT shows evidence of a pancreatic collection. (b) CT guided drain inserted Page 10 of 18
which confirmed pancreatic leak. (c) Pigtail drain within the collection. (d) Complete resolution of collection on follow up CT. Fig. 10: Patient post liver transplantation. (a) Arterial phase axial and (b) sagittal reconstructions showing hepatic artery stenosis. Angiography shows narrowing in the hepatic artery with some contrast still seen distal to the stenosis (c). Page 11 of 18
Fig. 11: Patient post liver transplantation. Arterial phase axial CT shows small amount of contrast within the main hepatic artery (a). Axial portal venous phase CT shows multiple areas of low attenuation within the liver in keeping with infarcts secondary to hepatic artery thrombus (b). Fig. 12: Hepatic artery bleed following liver transplantation on CT. (a) Unenhanced phase illustrating high density fluid in keeping with haemoperitoneum. Contrast extravasation demonstrated on the arterial phase images (b,c) in keeping with acute bleeding. Page 12 of 18
Fig. 13: Same patient as in Figure 12 post liver transplantation. (a) Angiogram demonstrates active contrast extravasation from the hepatic artery in keeping with active bleeding. (b) Angiographic result post successful coiling. Covered stent was also inserted in the transplant hepatic artery which had excluded a pseudoaneurysm. Fig. 14: Patient post liver transplantation. Coronal reconstruction of portal venous phase CT indicating filling defect within the main portal vein in keeping with thrombus. Page 13 of 18
Fig. 15: Patient post liver transplantation. (a) Initial venogram demonstrates narrowing of the proximal main portal vein in keeping with stenosis. (b) Result obtained following balloon dilatation. Pressure gradient fell from 12 (pre-dilatation) to 1. Fig. 16: Patient post liver transplantation for primary sclerosing cholangitis. Axial contrast enhanced CT demonstrates intrahepatic duct dilatation suggestive of recurrence (a). Page 14 of 18
Cholangiogram indicates long stricture in the main right intrahepatic duct (b) which was dilated with a balloon (c). Fig. 17: Patient post split graft liver transplantation. Contrast enhanced axial CT indicating a collection adjacent to the cut surface. Fig. 18: Patient presented with abdominal pain post laparoscopic cholecystectomy. ERCP demonstrated no contrast in the intrahepatic ducts (a). (b) Percutaneous transhepatic cholangiogram confirmed a disconnected common bile duct due to malpositioned surgical clips. Percutaneous external biliary drain was inserted to control the biliary obstruction until the patient was able to undergo biliary reconstructive surgery. Page 15 of 18
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Conclusion Early recognition of post operative complications following hepatobiliary surgery is crucial for optimising patient care A wide range of interventional radiology treatment options are currently available and have a pivotal role in patient management Page 17 of 18
References http://www.radiologyassistant.nl/en/p4375bb8dc241d/anatomy-of-the-liversegments.html Management of post hepatectomy complications. Jin S et al. World J Gastroenterol. Nov 28, 2013; 19(44): 7983-7991. CT after pancreaticoduodenectomy: spectrum of normal findings and complications. Raman SP, Horton KM, Cameron JL, Fishman EK. AJR Am J Roentgenol. 2013 Jul;201(1):2-13. US of Liver Transplants: Normal and Abnormal. Crossin JD, Muradali D, Wilson SR. Radiographics Sep-Oct 2003;23(5):1093-114. Review. Spectrum of Biliary and Nonbiliary Complications After Laparoscopic Cholecystectomy: Radiologic Findings. Kim JY et al. AJR Am J Roentgenol. 2008 Sep: 191(3):783-9. Page 18 of 18