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59. Gabbert C, et al. Advanced techniques for endoscopic biliary imaging: cholangioscopy, endo-
scopic ultrasonography, confocal, and beyond. Gastrointest Endosc Clin N Am.
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60. Arvanitakis M, et al. Intraductal optical coherence tomography during endoscopic retrograde
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61. Kirtane TS, Wagh MS. Endoscopic optical coherence tomography (OCT): advances in gastro-
intestinal imaging. Gastroenterol Res Pract. 2014;2014:376367.
29 Assessment of Bile Duct Tumors: Endoscopic vs Radiographic
341© Springer International Publishing Switzerland 2016
J.M. Millis, J.B. Matthews (eds.), Diffi cult Decisions in Hepatobiliary
and Pancreatic Surgery, Diffi cult Decisions in Surgery: An Evidence-Based
Approach, DOI 10.1007/978-3-319-27365-5_30
Chapter 30
Management of Signifi cant Hemobilia:
Hepatic Artery Embolization or Stenting?
Mikin V. Patel and Jonathan M. Lorenz
Abstract Hemobilia is a rare but potentially life-threatening cause of upper gastro-
intestinal bleed. Most common causes include iatrogenic injury and trauma with
pseudoaneurysm the most common anomaly identifi ed. Therapeutic options include
surgery, arterial embolization, or biliary stenting. Based on the etiology of hemobilia, endoscopic or percutaneous biliary covered stenting can be considered to tamponade the source of hemorrhage. However, in the majority of cases, angiography
is required to identify and, ultimately, treat the source of bleeding with arterial
embolization. Both arterial embolization and biliary stenting are effective, relatively
safe, and cost effi cient approaches to treatment of hemobilia which can be used
based on the etiology of hemorrhage.
Keywords Hemobilia • Embolization • Biliary stenting
Introduction
Hemobilia is relatively rare and can be diffi cult to recognize but is an important differential diagnosis for obscure upper gastrointestinal hemorrhage. Hemobilia arises
from communication between the biliary tract and vascular structures of the liver ,
hepatoduodenal ligament, extrahepatic biliary tree, gallbladder, or pancreas. As the
pressure differential between the venous system and an obstructed bile tree is relatively low, hemobilia is generally arterial in origin.
Although fi rst described by Francis Glisson in 1654 in a patient who sustained
penetrating abdominal trauma during a sword duel, the vast majority of cases today
are iatrogenic [ 1 ]. A review of 222 reported hemobilia cases from 1996 to 1999 by
Green et al. found 147 (66 %) were iatrogenic in etiology with trauma (5 %), most
M. V. Patel • J. M. Lorenz (*)
Department of Radiology , University of Chicago Medical Center ,
5841 S. Maryland Ave. MC2026 , Chicago , IL 60037 , USA
e-mail:
jlorenz@radiology.bsd.uchicago.edu
342
commonly motor vehicle accidents, gallstones (5 %), malignancy (6 %), vascular
(9 %), and infl ammatory etiologies (7 %) comprising the remainder [ 2 ]. Rare, iso-
lated cases of hemobilia resulting from ascariasis, amoebiasis, and heterotopic gastric mucosa have also been reported [ 3 – 5 ]. The majority of these reported cases of
hemobilia followed percutaneous liver biopsy with an incidence of 0.06–1 %, percutaneous cholangiography with an incidence of 0.7 %, or percutaneous biliary
drainage with incidence of 2.2–2.3 % [ 6 – 11 ]. However reports of bleeding as a
complication of endoscopic retrograde cholangiopancreatography ( ERCP ), particularly after sphincterotomy , are also reported with incidence of 2–9 % [ 12 – 15 ].
The cardinal features of hemobilia were described by Quincke in 1871 and
included upper gastrointestinal hemorrhage, upper abdominal pain , and jaundice
[ 16 ]. Based on clinical symptoms, hemobilia can be divided into minor hemobilia,
usually treated conservatively, and signifi cant hemobilia, which can be lifethreatening. As with any hemorrhage, initial management include resuscitation,
achievement of hemodynamic stability, and reversal of coagulopathies. Surgical
management of hemobilia focuses on ligation of the bleeding vessel and/or excision
of pseudoaneurysm with nonselective embolization of the right or left main hepatic
arteries and segmental liver resection as secondary options [ 2 , 17 ].
As many patients with hemobilia are acutely ill and unable to tolerate surgery ,
minimally invasive options for therapy are critical for stabilizing patients.
Transcatheter arterial embolization (TAE) is considered the interventional treatment
of choice; however covered biliary stent placement is a treatment option that can be
considered and is seeing increasing use, especially in cases of post- ERCP hemorrhage. This chapter addresses arterial embolization and biliary stenting as potential
surgical alternatives for treatment of hemobilia.
Search Strategy
A literature search of English language publications from 1999 to 2014 was used to
identity published data on treatment of hemobilia with arterial embolization or biliary stent ing using the PICO outline (Table 30.1 ). Databases searched were PubMed
and Embase. Terms used in the search were “hemobilia,” “hemobilia/embolization,”
“hemobilia/stent,” “biliary/hemorrhage/embolization,” and “biliary/hemorrhage/
stent.” Articles were excluded if they specifi cally addressed conservative treatment,
Table 30.1 PICO table for non-surgical treatment options for hemobilia
P (patients) I (intervention) C (comparator group) O ( outcomes measured)
Patients with
signifi cant
hemobilia
Selective hepatic
artery
embolization
Surgical ligation Hemobilia requiring surgical
intervention, procedure related
complication, LOS/return to work
Patients with
signifi cant
hemobilia
Biliary covered
stent placement
Angiographic
embolization, surgical
ligation
Need for additional intervention,
time to stent removal, adverse
events
M.V. Patel and J.M. Lorenz
343
endoscopic treatment other than stenting, or surgical treatment of hemobilia.
Thirteen cohort studies, nine case reports, and two reviews were included in our
analysis. The data was classifi ed using the GRADE system.
Results
Transcatheter Arterial Embolization
The existing literature regards TAE as the fi rst choice in therapy of signifi cant
hemobilia. TAE is used for aneurysms, pseudoaneurysms, arteriovenous malformations, malignancy, and hemangioma both as defi nitive treatment and as a bridge to
surgery for unstable patients. Portal vein thrombosis is a contraindication for TAE
as there is a signifi cant risk for infarction. The embolization is performed with gelatin sponge, microcoils, polyvinyl alcohol particles, or cyanoacrylate. Reviews and
retrospective studies have shown success rate s of TAE to be 75–100 % [ 2 , 17 , 18 ]
(Table 30.2 ). Technical failure occurs due to anomalous vascular anatomy or tortu-
ous vessels. Rebleeding is generally a consequence of collateral vessels.
Complications are generally limited to fever, abdominal pain , and elevation of
transaminases but also include hepatic or gallbladder necrosis, gallbladder fi brosis,
or hepatic abscess.
Most reported cases of hemobilia treated with TAE are either iatrogenic or posttraumatic and, at angiography, pseudoaneurysm is the most common anomaly found
irrespective of etiology. Marynissen reported successful treatment of hemobilia
with TAE in 12 patients, 6 of which occurred following liver biopsy, but 2 of which
followed ERCP with sphincterotomy [ 19 ]. Of the remaining patients, 2 had
hemobilia following percutaneous biliary drainage, one patient following a radiofrequency ablation, and one patient following cholecystectomy . The angiographic
evaluation revealed varying causes of hemobilia, most commonly pseudoaneurysm
Table 30.2 Clinical outcomes for transcatheter arterial embolization in hemobilia
Author (year) N
Mean
age
No cases requiring
surgery/ failure of TAE
Study type ( quality of
evidence)
Marynissen (2012) 12 48 0 Retrospective cohort (low)
Murugesan (2014) 12 34 3 Retrospective cohort (low)
Cao (2013) 8 46 0 Retrospective cohort (low)
Moodley (2001) 29 22 0 Retrospective cohort (low)
Srivastava (2006) 32 NR 8 Retrospective cohort (low)
Forlee (2004) 7 27 1 Prospective cohort (low)
Koh (2013) 2 54 1 Retrospective cohort (low)
Rivera-Sanfeliz (2004) 8 53 1 Retrospective cohort (low)
Nicholson (1999) 9 53 0 Retrospective cohort (low)
NR not reported
30 Management of Signifi cant Hemobilia: Hepatic Artery Embolization or Stenting?
344
(n = 6), but also including arteriobiliary and arterioportal fi stula e. Angiographic
fi ndings of the two cases following ERCP were not specifi cally identifi ed. Another
series of 29 patients successfully treated with TAE, of which 23 had hemobilia
related to penetrating or blunt abdominal trauma, found pseudoaneurysm in all
patients and associated arterioportal fi stulae in 4 patients [ 20 ].
Of the largest cohort studies, a series of 32 patients by Srivastava yielded a 75 %
success rate of TAE in controlling hemobilia at 1-month followup [ 21 ]. Of note, the
authors state that microcatheters were not used in this series, only 4-Fr and 5-Fr
catheters. A 12 patient series by Murugesan also yielded a 75 % success rate of TAE
with three failed embolizations due to inability to isolate the bleeding vessel, incomplete arterial occlusion, and misidentifi cation of the bleeding vessel [ 22 ]. However,
a number of smaller retrospective series with up to 29 patients report 100 % success
of TAE and a comprehensive literature review of cases from 1996 to 1999 reports
success of 80–100 % reinforcing an overall high success rate of TAE in controlling
signifi cant hemobilia [ 2 , 18 , 23 – 26 ].
Given the relatively low number of cases of hemobilia reported in the literature
and sparse data, it is diffi cult to estimate the benefi t of TAE in terms of the cost of
treatment or length of stay reduction. The recovery time from TAE is likely to be
considerably less than from surgery and, in a single series of 29 patients, all patients
were able to return to work within 2 weeks of embolization [ 20 ].
A number of complications of hepatic arterial embolization are reported, the
most common of which are fever, abdominal pain , and elevation of transaminases.
Post-embolization syndrome, a consequence of ischemic liver damage indicated by
transient elevation of liver enzymes is well-recognized and is seen in approximately
20–25 % of cases in most series but was as high as 75 % in a series reported by Cao,
although this did resolve with conservative treatment [ 21 , 23 , 24 ]. Major complica-
tions related to the embolization procedure are rare but isolated cases were reported
in the series reviewed. In one series, a patient who had hemobilia from trauma
developed gallbladder necrosis post-embolization which was noted at time of surgery [ 21 ]. Additional reported major complications included two separate patients
who developed hepatic necrosis, abscess, and sepsis [ 18 , 25 ]. Overall, however
morbidity and mortality is relatively low and hepatic artery embolization is considered the procedure of choice for unstable patients.
Biliary Stenting
As hemobilia typically presents as upper gastrointestinal bleeding, endoscopy is an
important diagnostic step in the evaluation of hemobilia to rule out common causes
of bleeding such as erosive gastritis, peptic ulcers, esophageal or gastric varices .
However, endoscopy is limited in specifi cally identifying hemobilia because the
bleeding is often intermittent and there may be biliary duct obstruction with thrombus preventing direct visualization of blood fl owing from the papilla of Vater. Most
series which evaluated hemobilia found that endoscopy was able to identify
M.V. Patel and J.M. Lorenz
345
hemobilia in only 24–60 % of cases [ 19 – 22 ]. On the other hand, angiography is
typically able to fi nd a vascular anomaly in over 90 % of hemobilia cases [ 19 , 22 ].
In addition to more commonly seen iatrogenic causes, ERCP with sphincterotomy often results in hemobilia, both immediately and in the delayed setting. This
presents a special circumstance because the site of bleeding can typically be visualized endoscopically. First line endoscopic therapy including epinephrine injection,
balloon tamponade, or thermal therapy is usually attempted. Typically, if these techniques fail patients require angiographic or surgical treatment. However, the use of
covered self-expandable metallic stents (SEMSs) to tamponade the site of bleeding
have also been reported.
The largest series of SEMS used to treat hemobilia included 11 patients, 10 of
whom presented with delayed post- sphincterotomy , and found successful hemostasis without need for TAE or surgery in all cases [ 24 ]. Other series of 6, 5, and 2
patients, most of whom presented with immediate post-sphincterotomy bleeding,
also found successful hemostasis in all cases [ 25 – 27 ] (Table 30.3 ). Theoretical
complications include acute cholecystitis or cholangitis induced by obstruction of
cystic or other bile duct s, however this complication has not been reported in the
literature. Of the larger case series described, spontaneous stent migration was seen
in 8 of 22 (36 %) of patients and in one case, rebleeding was seen [ 24 – 26 ]. No stric-
turing or proximal stent migration was noted. Additional case reports describe the
use of endoscopically-placed covered SEMS to successfully treat post- ERCP hemobilia forming a series of four successful cases of hemostasis achieved by endoscopic
stent ing [ 28 – 31 ].
SEMSs can also be used to treat hemobilia of certain other etiologies such as
hepatocellular carcinoma with bile duct invasion [ 32 , 33 ]. In one of these cases,
bleeding could not be stopped with TAE because the patient had undergone multiple
prior sessions of transcatheter arterial chemoembolization. Hemobilia can also be
treated with percutaneous stenting and can be the preferred option when there is a
pre-existing percutaneous biliary drain. Three such reported cases describe successful treatment of portobiliary fi stula with percutaneous stent-graft placement [ 34 ,
35 ]. Although isolated, these cases highlight applications in which biliary stent
placement in hemobilia when TAE is not feasible or when percutaneous biliary
access is already available.
Within the small set of reported cases of hemobilia there is an even smaller subset of cases treated by biliary stent placement. Although cost or length of stay is not
directly comparable with TAE or surgery , Shah et al. have suggested that biliary
Table 30.3 Clinical outcomes for biliary covered stenting in hemobilia
Author (year) N
Mean
age
Delayed
bleeding
No cases requiring
embolization/ surgery
Study type ( quality of
evidence)
Shah (2010) 5 62 2 0 Retrospective cohort (low)
Valats (2013) 6 68 1 0 Prospective cohort (low)
Itoi (2011) 11 76 10 0 Retrospective cohort (low)
Aslinia (2012) 2 42 2 0 Retrospective cohort (low)
30 Management of Signifi cant Hemobilia: Hepatic Artery Embolization or Stenting?
346
SEMS placement for hemobilia is likely a cost-effi cient alternative [ 26 ]. As ERCP
is typically an early step during evaluation of hemobilia, stenting of endoscopically
visible sources of bleeding may preclude the need for angiography. However, adequate data to suggest the true rates of success, complications, and cost of stent
retrieval are not currently available.
Recommendations
Hemobilia is a relatively rare cause of upper gastrointestinal bleeding with a variety
of etiologies and anomalies that can be identifi ed either angiographically or endoscopically. Although there is a distinct lack of high-quality clinical trial s or large
cohort studies, there are a number of small case series supporting the use of arterial
embolization and biliary stent ing . The body of evidence supports the use of endoscopic biliary covered stent placement to tamponade the source of bleeding when
the anomaly is readily identifi able and accessible such as in the case of post sphincterotomy bleeding. Additionally, in cases where percutaneous biliary access
has already been established, percutaneous biliary stent placement is also an option.
However, when there is risk of biliary duct obstruction, arterial embolization may
be preferred.
In the majority of reported cases, hemobilia is due to iatrogenic injury from procedure such as liver biopsy or percutaneous biliary drain or from abdominal trauma.
In these situations, endoscopy has demonstrated a low yield in identifying the source
of hemorrhage. Angiography can identify the vascular anomaly in over 90 % of
patients and treatment with TAE is successful in 75–100 % of cases. Reported complications are rare and patient generally recover quickly. Thus, except in cases
where the anomaly is easily visualized on endoscopy or accessed percutaneously,
we make a weak recommendation that hemobilia be evaluated and treated with
angiography and TAE.
A Personal View of the Data
Hemobilia is relatively rare but optimal treatment relies on thorough consideration
of the underlying etiology and anomaly. For post- sphincterotomy bleeding, biliary
stent ing is likely the fastest and most cost effi cient option for treatment. Additionally,
in the circumstance where the patient has percutaneous biliary access in place and a
portobiliary fi stula can be identifi ed, biliary stent placement can be a viable option.
However, most cases of hemobilia will not be easily amenable to or may be refractory to biliary stenting. Angiography is highly sensitive in identifying the source of
bleeding and embolization has a high success rate with relatively rare complications
so TAE continues to be the mainstay of treatment. In either case, whether placing a
biliary stent for tamponade or embolizing angiographic abnormalities, these
M.V. Patel and J.M. Lorenz
347
interventional options reduce the cost of treatment and time to recovery for patients
with hemobilia.
Recommendations
• For the majority of patients with hemobilia, angiography and transcatheter arte-
rial embolization should be the mainstays of evaluation and treatment (evidence
quality low; weak recommendation).
• For patients with hemobilia post- endoscopic intervention, we recommend an
attempt at biliary covered stent placement at the time of endoscopy (evidence
quality low; weak recommendation).
• We recommend considering percutaneous biliary covered stent placement if the
patient already has percutaneous biliary access (evidence quality low; weak
recommendation).
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M.V. Patel and J.M. Lorenz
349© Springer International Publishing Switzerland 2016
J.M. Millis, J.B. Matthews (eds.), Diffi cult Decisions in Hepatobiliary
and Pancreatic Surgery, Diffi cult Decisions in Surgery: An Evidence-Based
Approach, DOI 10.1007/978-3-319-27365-5_31
Chapter 31
The Assessment of Ductal Margin in CurativeIntent Surgery for Perihilar
Cholangiocarcinoma
Nobuhisa Akamatsu , Yasuhiko Sugawara , and Norihiro Kokudo
Abstract In the surgical approach for perihilar cholangiocarcinoma, one of the
most important aims is to achieve a bile duct margin-negative resection because a
negative resection margin is a crucial determinant of prognosis after curative-intent
resection. Advances in the knowledge of perihilar anatomy and surgical techniques,
including perioperative management, have made an extended hepatectomy with
complete resection of the caudate lobe the recommended approach for a promising
outcome after curative-intent surgery for perihilar cholangiocarcinoma. Enhanced
multidetector-row computed tomography (MDCT) with three-dimensional and
multiplanar reconstruction is necessary for both a precise preoperative evaluation of
the tumor extent and safe and curative surgical resection, while the gold standard for
preoperative assessment of the bile duct margin is cholangiography or MDCT/magnetic resonance cholangiography, depending on the surgeon’s preference.
Keywords Ductal margin • Cholangiocarcinoma • Resection • Multidetector-row
computed tomography • Tumor extent • Preoperative assessment
Introduction
Perihilar cholangiocarcinoma is a devastating disease, and its surgical resection is
technically demanding and highly challenging for hepatobiliary surgeons. Complete
surgical resection is the only way to cure this disease, leading many surgeons to
adopt an aggressive approach to perihilar cholangiocarcinoma. With advancements
in the knowledge and surgical techniques for this disease, curative-intent surgery for
perihilar cholangiocarcinoma includes complete extrahepatic bile duct resection,
N. Akamatsu • Y. Sugawara (*) • N. Kokudo
Hepato-Biliary-Pancreatic Surgery, and Artifi cial Organ and Transplantation Division,
Department of Surgery, Graduate School of Medicine , University of Tokyo ,
7-3-1 Hongo , Bunkyo-ku , Tokyo 113-8655 , Japan
e-mail:
yasusuga-tky@umin.ac.jp