Causes and Treatment of Bile Leaks at the Puncture Site After Percutaneous Transhepatic Biliary Decompression
Authors: Rasekhi Alireza , Kondori Nasir Babakhan 
Published: September 2019

Introduction:
Bile leaks at the puncture site after percutaneous transhepatic biliary decompression (PTBD) are not uncommon and cause a lot of problems for patients with non-resectable biliary malignant obstruction. However, to the best of the authors’ knowledge, no study is conducted to establish the causes and to find an appropriate treatment. The current study was conducted on 264 patients who underwent PTBD for a malignant biliary obstruction.

Material and Methods:
This retrospective study reviewed 264 patients with non-resectable malignant biliary obstruction requiring PTBD. A two-stage biliary decompression is done. An 8Fr pigtail catheter is placed for PTBD, the patients would return after two days for stent placement. After stent placement, an 8 Fr pigtail catheter (internal – external) would be placed for flushing, and also for cholangiography. The patients are then observed for another two days. Patients who have persistent puncture site bile leakage after 24 hours are considered to have a bile leak. In these patients, cholangiography is performed. If cholangiography reveals stent occlusion, stent reopening by irrigation/ballooning is done. For those with patent stents and bile leakage, an internal-external biliary drain is placed which does not solve the problem, and a cholangiography is done into the drain tract via a syringe.

Results:
Sixteen of 264 patients who underwent percutaneous biliary decompression developed bile leakage at the puncture site. Twelve of these patients demonstrated an occluded biliary stent and their bile leak resolved after irrigation/ballooning. Four patients with bile leak demonstrated patent biliary stents and persistent leakage despite internal-external biliary drain placement. Cholangiograms in these patients demonstrated connections from the stented biliary system (the ipsilateral system), branches of a different occluded biliary system (the contralateral biliary tract), and the drain tract. All four patients underwent PTBD of the contralateral biliary system with subsequent resolution of their bile leak.

Discussion:
One of the complications of PTBD is bile leakage at the puncture site which could have two reasons. The most common is stent occlusion by clot and debris which can be managed by irrigation/ stenting. The second mechanism of bile leakage, not reported previously, was a fistulous connection between the drained biliary system (the ipsilateral system) and a separate obstructed biliary system (the contralateral system).
We would like to refer to this mechanism of bile leak “Yo-Yo reflux” for its specific pattern of cholangiography. The Yo-Yo reflux mechanism of bile leaks occurs when a small branch from the adjacent separated contralateral system is transgressed inadvertently during ipsilateral biliary drainage. High-pressure bile fluid from the obstructed system flows through the lower pressure ipsilateral system and through the cannulation tract and onto the skin surface. In the Yo-Yo mechanism, stenting of the contralateral side is the only treatment.

Conclusion:
Bile leakage at the puncture site after PTBD has two major causes. The most common is stent occlusion by clot/debris which is diagnosed by cholangiography and treated by irrigation/ballooning. The second cause is Yo-Yo reflux which is diagnosed by cholangiography injecting directly into the orifice of skin fistula and treated by contralateral stenting.