key: cord-1029778-phskfriu
authors: Yang, Alan; Mitchell, Matthew; Di Capua, John; Som, Avik; Huang, Junjian; Weissleder, Ralph; Kalva, Sanjeeva; Uppot, Raul
title: Microwave Ablation for Resolution of Persistent Biloma Following Hepatectomy and Cholecystectomy: Case Report
date: 2021-11-05
journal: Cardiovasc Intervent Radiol
DOI: 10.1007/s00270-021-02999-8
sha: b5f3b9fe149d303d7e12e7ced6dad374fd794fb5
doc_id: 1029778
cord_uid: phskfriu

nan

The authors present a case of a patient who, after receiving a partial, non-segmental hepatectomy and cholecystectomy, developed a biloma which persisted for *2 years and was finally cured with microwave ablation (MWA) following several ineffective attempts to treat with drainage catheterization, embolization, and biliary stenting (Fig. 1) .

A 43-year-old male with a previous history of ulcerative colitis and primary sclerosing cholangitis presented to the operating room in March 2018 for right partial hepatectomy, open cholecystectomy, and portal lymphadenectomy for recently diagnosed cholangiocarcinoma. On postoperative day 9 the patient was found to have a fluid collection (4.3 cm 9 9.1 cm) along the hepatectomy resection margin. A12 Fr multipurpose (MP) catheter was placed into the collection with aspiration of 600 cc of purulent fluid. Because of continued drainage over several months, the patient was transferred to the authors' institution.

Upon admission, the 12 Fr MP drainage catheter had persistent bilious output of *100-150 cc/day. Three 7 Fr plastic stents were placed via ERCP in the hope of diverting flow. The patient received several selective abscess drain studies with an attempt to define the biliary leakage site over the next 7 months. Initially these demonstrated a single bile duct emptying into the cavity, but re-imaging revealed at least four separate leaking ducts-an unusual presentation (Fig. 2) . In October 2018, several selective percutaneous onyx embolizations of the injured biliary ducts were performed. Despite decreased output initially, over time the patient continued to experience biliary leakage.

Thus, in January 2020 a CT-guided percutaneous MWA of the prior hepatectomy resection margin was performed to stricture the leaking biliary ducts. A 2.45 GHz 16-gauge 15 cm antenna applicator (HS-AMICA-Gen, H.S. Hospital Service S.p.A., Rome, Italy) was advanced into the region of the leaking bile ducts. One thermal ablation was performed using 60 watts x 5 min; we chose energy settings based on antenna spacing and expected thermal volumes. Subsequently, the antenna was advanced into the inferior bile duct, and another thermal ablation was performed for 20 watts x 3 min. No liver separation via hydrosissection or other methods was necessary. Post-procedural CT did not reveal any immediate complications. A 10 Fr catheter was left in the resection bed.

During the month following the MWA, drainage injections showed a small persistent fluid collection along the hepatectomy margin, and the patient reported drainage of *50-60 cc/day. No further tube injections took place in the ensuing *4 months due to the COVID-19 pandemic. During this intervening time, the patient reported a decrease in the volume of bilious leakage. Three months after the ablation, there was scant serous output, and the drainage catheter was capped a month later. 4.5 months after the ablation, drain injection and CT showed expected retraction of the ablation zone and decreased biloma size (1.6 cm 9 1.2 cm). The percutaneous drainage catheter was removed. 21 months after the ablation, the patient has undergone another 5 MRCPs, 2 MRIs, and 4 CTs with no evidence of recurring biliary leakage. This case represents an uncommon attempt to treat a biloma with MWA. Several treatment options exist for persistent biliary leakage from isolated bile ducts. Ductal packing with onyx or glues has been attempted with mixed results [1, 2] . More recently, ethanol injections have been advocated to sclerose biliary ducts [3] . Finally, ablative methods such as RFA and MWA have been used to ablate hepatic tumors and surrounding hepatic parenchyma [4] . Based on the timeline of treatments, the authors believe that MWA was successful in treating this patient as the microwave ablation cavity slowly healed over several months. The initial persistent biliary leakage immediately following MWA could have been due to residual untreated smaller ducts which sclerosed over time with hepatic healing. Regardless, a decrease in biloma size was only noted after the MWA procedure (Fig. 3) , and no other treatments were given during that time.

Funding This study was not supported by any funding. Consent for Publication For this type of study consent for publication is not required.

Ethical Approval For this type of study formal consent is not required.

The study was HIPAA compliant and approved by the Institutional Review Board with waiver of patient consent. For this type of study informed consent is not required.

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