Cystic Duct Embolization to Manage Postoperative Bile Leaks after Subtotal Cholecystectomy

The goal of this study is to demonstrate the efficacy of cystic duct embolization in a larger cohort, using both antegrade and retrograde approaches as well as a variety of less commonly used embolic agents for this procedure, specifically liquid embolic and plugs.

Materials and Methods:

This is a single-institution retrospective study reviewing the procedural approach and clinical course of all adult patients who underwent cystic duct embolization for management of a continued bile leak after subtotal cholecystectomy between January 2018 to December 2023 at a tertiary-referral center to determine the efficacy of the procedure. No< ![if !supportAnnotations] >[KME1]< ![endif] >  standardized embolization technique was used. All procedures were completed with fluoroscopic guidance. Embolization was performed until appropriate stasis was visualized.

Results:

Six patients were identified that met inclusion criteria. All patients were biologically male and mean age was 56.0 ± 7.5 years old. Mean number of days from surgery to leak identification was 3.5 ± 4.2, however five of the six patients had a biliary leak identified within the first 3 days post-surgery. After leak identification, all six patients had ERCP performed or attempted prior to cystic duct embolization. The average time from cholecystectomy to embolization was 29.5 ± 25.3 days. The cystic duct was accessed primarily using a retrograde approach via the gallbladder fossa. However, one procedure was performed utilizing the antegrade approach, through an existing internal-external biliary drain. Embolization was performed with a variety of embolic materials. In five of the six patients, embolization was performed with an 8mm Amplatzer IV plug with one of the five also embolized with a glue mixture (1 nBCA: 2 lipiodol). For the sixth patient, embolization was performed with 6mm detachable Azur coils followed by Onyx. All patients had a completion cholangiogram demonstrating appropriate stasis of the cystic duct. There was one documented complication of plug displacement during wire removal. The plug was retrieved and a new plug was deployed in its place. One patient required repeat embolization with Onyx four months after initial embolization due to continued communication between the subhepatic space and cystic duct stump.

Conclusion:

Cystic duct embolization using a variety of embolic materials including plugs and liquid embolic is a feasible, safe and successful intervention to manage bile leaks after other methods of management, such as percutaneous drainage and biliary stents, fail.