Assessment of Technical and Clinical Success of Percutaneous Transhepatic Biliary Drainage in the Treatment of Postoperative Biliary Insufficiency using an Interventional Escalation Strategy

Le résumé fourni par la source

Purpose: Surgical treatment of postoperative insufficiency in the bile ducts, bilio-digestive anastomosis (BDA) and cystic duct stump is associated with high morbidity (22–37%) and mortality (3–18%). The insufficiency of the BDA (0 to 5%) and that of the cystic stump (0.3 to 3%) is a frequent complication after the various biliodigestive operations of liver and pancreas. The goal of this study was to evaluate the role of percutaneous transhepatic biliary drainage (PTBD) using an escalation strategy in the management of postoperative bile leaks. Our primary study endpoint was technical and clinical success defined as remission of the insufficiency and outcome of the patients (morbidity and complications) with secondary study endpoints as analysis of the duration, number and types of PTBD-interventions, infection parameters, and patients survival. Materials and Methods: We retrospectively (from 1.1.2018 to 1.10.2021) analyzed 24 patients (14 males, 10 females, mean age of 69.33 ± 11.7 years with a range of 45–93), who had been transferred to our radiological department by the department of visceral and abdominal surgery for PTBD placements due to postoperative biliary insufficiency. We placed 23 PTBDs followed by 107 follow-up interventions under a strict escalation strategy involving sequentially larger drainages (8, 10, 12F) and manually modified PTBDs with side holes manually cut out with sparing the area of the insufficiency. Additional to the 130 percutaneous biliary interventions altogether, if necessary we placed additional CT- or ultrasound-guided percutaneous drainages in perihepatic bilomas. Results: Altogether we performed 141 interventions (PTCD and drainage) on the 24 patients. The average interventional therapy lasted 56.87 ± 68.48 days (range of 2–239). In the retrospective, technical success was achieved in 95.8% of cases and a clinical success rate of 58.3% (success in 15 patients, unsuccessful in 2, dropout under ongoing interventional therapy in 7). Direct therapy, involving immediate PTBD use, demonstrated a high interventional success rate (69.5%) and was associated with a significant reduction in C-Reactive Protein levels (14.96 to 9.66) and bile levels (6.65 to 0.7). In contrast, indirect therapy, comprising subsequent surgical reintervention followed by PTBD, showed increased complications and mortality compared with direct therapy. Male gender was associated with a higher likelihood of transabdominal drainage. These findings underscored the clinical significance of therapeutic approach selection, with direct therapy offering favorable biochemical responses and improved post-surgery outcomes. There were 2 (8,80%) major complications after interventions (2 liver hematomas), but no interventional-related mortality. Conclusion: Our retrospective analysis highlights the efficacy of direct therapy, involving immediate PTBD, in addressing postoperative biliary insufficiency. Technical success and favorable biochemical responses underscore the importance of this approach. Conversely, indirect therapy, despite being employed in challenging cases, was associated with increased complications and mortality. Gender differences further influenced the choice of therapeutic intervention. These findings emphasize the need for a tailored and judicious selection of therapeutic strategies, taking into account both technical feasibility and patient characteristics. Improved outcomes observed with direct therapy suggest its potential as a primary intervention in the management of postoperative biliary complications. Publication History Article published online: 02 April 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Stuttgart · New York

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.