ARRS 2022 Abstracts

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E2113. Oh Bili! A Review of Biliary Anastomoses, Complications, and Interventions
Authors
  1. Stephanie Jankovic; University of Rochester Medical Center
  2. Marc Michael Lim; Oregon Health & Science University; University of Rochester Medical Center
Background
Biliary anastomoses are a mainstay in hepatobiliary surgeries such as liver transplant and Whipple procedure. They are also frequently utilized in instances of trauma, for example bile duct injuries during laparoscopic cholecystectomy. There are multiple types of biliary anastomoses, some of which have very complex anatomy, which then have unique postoperative complications. The imaging appearances of normal postoperative versus abnormal anastomoses may be difficult to differentiate for the radiologist who is unfamiliar with their complex anatomy. Additionally, various endoscopic and/or percutaneous interventions are utilized to address these complications.

Educational Goals / Teaching Points
This exhibit aims to review the various types of biliary anastomoses that may be encountered in patients after liver transplant (living or deceased donor), Whipple procedure, and trauma, with both pictorial diagrams to delineate the anatomy as well as multimodal imaging; correlate imaging appearances between CT, fluoroscopic cholangiogram, and MRCP; present the complications that arise from these anastomoses, such as stricture and leak, as well as the specific imaging findings; and discuss subsequent interventions that may be required, including endoscopic and/or percutaneous stent and drain placement, as well as their postprocedure imaging appearances.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Biliary anastomoses are categorized into primary biliary, such as choledochocholedochal, and biliary-enteric, such as hepaticojejunostomy as seen in Whipple procedures. Their subtypes also include less commonly encountered anastomoses, such as the cholecystoduodenostomy, in which the gallbladder is directly anastomosed to the duodenum. In post-liver transplant patients who develop strictures at the anastomosis between the native and donor ducts, a benign stricture protocol may be followed in which patients undergo percutaneous internal/external biliary drain placement to stent the stricture open. These are subsequently upsized over the course of several weeks and months, until such time, as the duct will remain open on its own. Occasionally, strictures may be so severe and require complex interventions, such as in a rendezvous procedure in which endoscopic and percutaneous approaches are simultaneously utilized to cross the stricture and place a stent.

Conclusion
Biliary anastomoses can have complex imaging appearances if one is not familiar with the anatomy, as well as various post-operative complications. Accurate recognition of complications on multimodal imaging is imperative to allow for appropriate intervention, such as endoscopic and/or percutaneous stent and drain placement.