Figure 1 Percutaneous transhepatic cholangiography (PTC) showing the dilated segmental intrahepatic ducts excluded by the main biliary duct. A plastic stent is placed prompt delivery in the main duct. Figure 2 Cholangiogram showing the guide wire (arrow) during unsuccessful attempts to cross the anastomotic obstruction. We supposed that the segmentary bile duct branch of posterior segments VI and VII draining in the left bile duct was unidentified and tied at the time of the in situ split-liver procedure during the parenchymal transection. A primary biliary reconstruction by biliary repair or biliodigestive anastomosis was considered at high risk because of the presence of postsurgical adhesions sand due to fibrotic tissue replacing the parenchymal transected area.
A liver resection of the dilated segments VI and VII was considered at high risk of leaving an inadequate liver mass. We decided to perform a permanent intraoperative obliteration of the dilated intrahepatic ducts by a percutaneous embolization using a nonresorbable agent. With a fluoroscopic guidance through the transhepatic access we positioned a 5-French polyethylene catheter inside the ducts, preliminary flushed by a nonionic dextrose solution. We then injected the tissue adhesive agent n-butyl cyanoacrylate (NBCA, Glubran 2, GEM, Viareggio, Italy) mixed with ionized oil (Lipiodol, Guebert, Aulnay-sous-Bois, France) for opacization in a ratio of 1:5. This solution completely filled the biliary duct, and the occlusion was totally accomplished in a few seconds (Figure 3).
Figure 3 Intraoperative cholangiogram showing the complete filling with glue of excluded intrahepatic bile ducts. During the first 3 days after the chemical bile duct embolization, the patient had a low fever with a slightly abnormal liver function test. A computed tomography (CT) scan performed 6 months later showed no sign of hepatic abscesses, and the bile duct dilatation was completely occupied by the NBCA-Lipiodol mixture. One year after the procedure patient showed normal liver function tests without no episodes of cholangitis. 3. Discussion The management of biliary complications after liver transplantation requires a multidisciplinary approach. Chemical bile duct embolization treatment could represent a valuable solution to treat uncommon biliary complications.
These tissue adhesive glues are low-viscosity liquid monomers that undergo rapid polymerization and solidification when they come into contact with organic fluids such as bile. NBCA is a permanent liquid embolic material that produces long-term Drug_discovery occlusion in vessels of various size through an inflammatory tissue response resulting in vessel thrombosis or tissue atrophy. Little is known about the use of cyanoacrylate compounds, and unlike European countries the use of Glubran has not been approved by the Food and Drug Administration yet.