Complex biliary intervention: Percutaneous small bowel access confirmation with cone-beam computed tomography and retrograde biliary obstruction recanalization

Background : To describe our experience with percutaneous small bowel access in patients with surgically altered anatomy for complex biliary intervention where cone-beam computed tomography (CBCT) was used to confirm appropriate small bowel access. Methods : Retrospective chart review from January 2012 to February 2016 identified 9 patients who underwent complex biliary procedures, which used CBCT assistance. Inclusion criteria were creation of percutaneous small bowel access, usage of CBCT, and biliary recanalization. Procedures were performed using percutaneous small bowel access to assist with antegrade or retrograde biliary recanalization using a variety of wire and catheter techniques. Non-contrast CBCT was used in all cases to confirm appropriate small bowel access. Results : In three patients with disconnected biliary systems and failed prior attempts at percutaneous recanalization, new bilio-enteric anastomoses were successfully created. In 6 patients with prior hepaticojejunostomy and biliary obstructions, percutaneous jejunostomy was used successfully to recanalize the biliary stenoses and place multiple internal biliary stents, which were then managed with percutaneous retrograde exchanges. Five patients are catheter free; two are currently managed with long-term biliary drainage. One patient eventually required liver transplantation and another required surgical revision of anastomotic restenosis. There was a single major complication in one patient where the jejunostomy tube resulted in small bowel obstruction requiring surgical revision. A minor complication occurred in another patient, with the development of cellulitis around the jejunostomy tube. Conclusion : CBCT can effectively confirm appropriate percutaneous small bowel access in patients with surgically altered anatomy, and who require retrograde biliary recanalization. CBCT is also useful to guide percutaneous creation of new bilio-enteric anastomosis in patients with disconnected biliary systems.