A 54 year old Male underwent Non Anatomical resection for Cholangiocarcinoma involving Seg 5/6 in December 2018. He developed perihepatic collection for which he had undergone percutaneous catheter drainage 3 times. Last drainage was done about 2.5 months back in June 2019. ERCP and CBD stenting done in Feb/March 2019 failed to stop the leak which ranged about 20-25 ml a day. He has no abdominal pain or fever. He has undergone percutaneous transhepatic glue injection on 20th July 2019 as MRI showed a small collection communicating with ductal system on the right side (Segment 7). Post the procedure, the daily discharge has fallen to about 9-10 ml/day. (It has reduced but had not been arrested). What is the appropriate next step to take in this regard to stop the leak ?
Can you send us the cholangiogram( ERCP) ? What we know about this kind of leakage is that in most cases there is a liver segment which biliary duct does not communicate with the main biliary duct that means that there is a disconnected hepatic segment (similar to disconnected pancreas)and therefore is not going to close and a reresection is needed
Thank you for the response Dr. Machado.
Attached please find ERCP and MRI reports before glue injection.
Since there is no leak demonstration in ERCP it is possible that there is a disconnected liver segment What should be interesting is to compare the MRI with ERCP try to find a liver segment that is not connected to the main biliuary tree
I agree with Dr Machado that this sounds like a segment that is disconnected from the downstream Biliary tree. Besides doing surgical re-resection of segment 7, you could do radiation segmentectomy using Y-90. This would require your interventional radiologist to superselectively cannulate the artery to segment 7 and infuse a relatively high dose of Y-90 which will subsequently induce radiation necrosis and atrophy with cessation of bile flow.
Thank you for your valuable inputs Dr. Fung@ John Julian Fung and Dr. Bale@ Reto Bale
Agreeing with Prof. Fung I would vote for surgical exploration and most possibly re resection.
it is obvious that disconnected functional liver tissue has to be removed or destroyed. whether the disconnected sub/segment is resected or destroyed by thermal ablation / sirt depends on the local expertise. but if there are signs of infection (wbc, imaging) i would definitely go for resection. if not i would suggest minimal invasive ablation.
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