Complications of Percutaneous Biliary Procedures

Percutaneous biliary and gallbladder drainage is routinely performed by interventional radiology. These pathologies and techniques are well described in the literature and in this issue. The purpose of this review is to focus on the recognition and management of complications. Percutaneous biliary drains can have a variety of complications which can range from minor skin issues to more serious and complex bleeding issues. Advancements in imaging and techniques improve the safety profile of percutaneous biliary and gallbladder interventions.

biliary interventions, percutaneous transhepatic cholangiography, biliary drains The safety profile of percutaneous biliary and gallbladder interventions has improved due to advancements in imaging and techniques. 1 In this article, we discuss the complications associated with these percutaneous procedures. Appropriate and timely recognition and management of these complications is integral to doing these cases. Preprocedure and Immediate Postprocedure Observations to Minimize Complications When consulted for new biliary/gallbladder intervention, patients are often introduced to the interventional radiology (IR) department and told that this is the beginning of a relationship for follow-up procedures. Creating this trust with patients allows for setting expectations and efficient management of complications. Easy access to the IR team for questions and concerns builds upon the trust which patients and caretakers place in our expertise. Preprocedure Observations Biliary interventions are considered high bleeding risk procedures that require careful assessment of factors that could increase the chance of procedure-associated bleeding. Patients with hematologic disorders, bleeding diathesis, chemotherapeutic agents, or anticoagulation therapy are at an inherently high risk for postprocedure bleeding. The following preprocedural workup is recommended according to Society of Interventional Radiology Guidelines: Patient evaluation by history and physical examination to include careful review of medications. Review of available imaging for preprocedure planning. - Preprocedure laboratory assessment to include but are not limited to: Hemoglobin ≥8; hematocrit 24. Platelet count with plan for correction to counts ≥50 × 10 9 /L. Prothrombin time/international normalized ratio (INR) especially in patients on warfarin with recommendation to correct within range of INR ≤1.5. Ensure NPO (nothing by mouth) status according to institutional guidelines. - Intravenous (IV) access: For conscious sedation administration. Rapid access for infusion of medications, IV fluids, and/or transfusion products. - IV antibiotics where appropriate: Unasyn: 1.5 g or organism specific. - If penicillin allergy: i. IV ceftriaxone 1 g (<90 kg); 2 g (≥90 kg). ii. IV vancomycin 1 g (120 kg). iii. IV ciprofloxacin 400 mg and Flagyl 500 mg. Intraprocedural Observations In some instances, bleeding can be seen during the case. Pulsatile bright red blood coming from the access site or into the drain is an indication to perform an emergent angiography. If purulent fluid comes out when access is obtained, minimal manipulation (and contrast injection) in the biliary system should be performed to minimize sepsis following procedure. Additional antibiotic coverage may be needed. Changes in hemodynamic status should be observed closely. Immediate Postprocedure Observations After completion of IR biliary procedures, patients are observed either in the postanesthesia care unit, IR recovery area, or their inpatient beds (if in intensive care unit [ICU]). Close postprocedure monitoring of vital signs when employed in correlation with the patient's specific clinical status can lead to early detection of complications with improvement of outcomes in management. 2 The risk thresholds are presented in Table 1 . 3 Prior to assessing patient for potential complications, the following should be evaluated: Table 1. Risk thresholds. | Physiologic parameters | Warning threshold | |---|---| | Heart rate | ≥110 or ≤55 beats/min | | Respiratory rate | ≥25/min or ≤10 breaths/min | | Systolic blood pressure | ≤90 or ≥200 mm Hg | | Glasgow coma score | <15 | | Oxygen saturation | <90% | | Urine output | 100 mL over 4 h | | Temperature | 38°C | IV access. Complete blood cell count, coagulation profile, liver function tests (LFTs), type and screen. Intravenous fluids (IVF) or IV antibiotics where appropriate. Review notes and procedure with performing physician to come up with differential for complication. Imaging where appropriate. Percutaneous Biliary Interventions: Complications and Management of Complications Biliary Drain–Related Complications Catheter Occlusion One of the most common catheter complications is occlusion. Bile is a viscous fluid and this leads to biliary debris clogging the catheter. In some instances, extrinsic compression leads to kinking or narrowing of the lumen. Tight suturing for securement can also cause drain occlusion. Prevention: Educate the patient and caregivers on how to flush the catheter per institutional guidelines. Flushing of drains that are across the ampulla may lead to an increased risk of cholangitis. However, flushing drains (10 mL saline twice a day) can help keep the drain patent. Recognition: It is difficult to educate patients on how to evaluate patency of the drains. Drain output is variable as drainage could be internal (into the bowel) or external (into the bag). Leakage, pain, jaundice, pruritus, white stools, dark urine, and fevers should prompt consideration of drain occlusion. Sometimes, routine laboratory evaluation (without clinical symptoms) suggests occlusion such as a rise in bilirubin or alkaline phosphatase. Management: Contrast study through the existing catheter is gold standard to demonstrate occlusion. Consider exchanging or upsizing the catheter. Catheter Dislodgement Biliary catheter migration and dislodgement (internally or externally) is a common complication. Many biliary drains are placed using an intercostal approach which produces frequent movement in and out of the skin. Catheters attached to bags can become caught on clothes or other items resulting in more movement of the catheter. Biliary catheters are looped catheters (loop in the bowel) which contain an internal locking mechanism which allows it to be secured in place. The catheter securement may then be reinforced with a suture and contained within a secure fixation device. However, even with multiple reinforcements, accidental catheter dislodgement may occur when any part of the catheter/tubing get caught. When enough force is applied, catheter removal may also occur with intention, especially in patients with altered mental status. Biliary drain dislodgement is much more common with external biliary drains (short catheters with pigtail partially formed in the biliary ducts). The loop formed in the duodenum/jejunum for internal–external biliary drains limits dislodgement. Internal migration of internal–external biliary drains may lead to the side holes not crossing the stricture leading to malfunction (functional occlusion). External migration may lead to side holes in the subcutaneous tissue and/or peritoneum ( Fig. 1 ). This can lead to subcutaneous abscesses/skin irritation and peritonitis. Prevention: Patient, medical staff, and caretaker education on drain management can minimize dislodgement. Each component of the drainage system should be secured to prevent additional traction on the catheter. A soft abdominal binder can be placed over the drainage catheter in patients who are at risk of self-removal of catheters. Recognition: Patients may present with a history of trauma to the catheter which may be associated with new pericatheter pain, catheter leakage (with or without flushing), or lack of output from catheter. Examine the catheter site to assess the integrity of the suture and fixation device. Consider flushing the catheter to assess for immediate leakage of flush through the tract. If the radiopaque (black) marking on the catheter or catheter side holes is visible, this definitely suggests that the catheter is externally dislodged. Patients may also present with the catheter already fully externalized. It is important to inspect the catheter to ensure there is no fragmentation. Interview family or caretakers if the catheter is not available for inspection. Imaging studies such as abdominal radiography, CT, and/or contrast study through catheter would help assess for catheter placement especially if there is concern for catheter fragmentation during dislodgement. Management: For partial dislodgement of catheter, preprocedure IV antibiotics and exchange/repositioning of catheter may be performed. In cases of complete dislodgement (especially if the tract is well formed), catheter/wire can be advanced through the tract to replace the drain without having to re-puncture the biliary system. Rarely, a new percutaneous transhepatic cholangiography (PTC) has to be performed to place a new drain. Catheter Fracture A less common complication is catheter fracture. This is seen when the bile salts cause the catheter to become hard and brittle. This can cause the end of the catheter to crack or break off completely and can be seen when doing catheter exchange. External sutures can be obstructing to the catheters and may cause kinking or obstruction. When securing the catheter, it is important to make sure the suture is not too tight. 4 The risk of catheter fracture is related to the location of the catheter, the type of catheter, and the duration of placement. The patient may reveal a history of trauma to the catheter, catheter leaking with or without flushing, and pain. In addition, accelerated catheter damage occurring at the point of side holes situated within enteric contents have been reported with certain biliary catheters. 5 Prevention: Prevention of catheter fracture begins when planning the approach for catheter placement. Anatomic variables causing excessive extrinsic forces in the path of the catheter such as the inferior border of the rib cage should be avoided when possible. Inspect the catheter for kinking and ensure sutures or fixation devices do not contribute to pressure points along the catheter. Regular routine exchange per recommendations from catheter manufacturers should be ordered before the patient is discharged from the hospital. Recognition: Inspect the catheter for any visible side holes, defects, kinking, or leaking. Flushing the catheter gently with 5 to 10 mL of normal saline may reveal the site of catheter fracture. Gentle aspiration of the catheter demonstrating air in the syringe would suggest catheter defect along the tract. Imaging with fluoroscopy/radiography or CT and/or cholangiography may be needed to reveal deeper catheter-related fractures if exchange of the catheter reveals incomplete catheter retrieval. Management: Kwan et al described a case of catheter fracture with subsequent retrieval via radiological, endoscopic, and open techniques. 6 There is no standard treatment approach in addressing catheter retrieval. While some interventional radiologists may decide not to retrieve a catheter based on location and risk of biliary obstruction, others may choose to retrieve it for risks of infection. A multiservice approach for removal may be required. Catheter removal may be achieved in IR such as over the wire balloon catheter, biopsy forceps, or snare use. For cases that preclude IR retrieval, endoscopic or surgical approaches may be considered with expert consultation. In cases of partial fracture, drain exchange over a wire is recommended. Bile Leakage Bile leakage can occur due to catheter occlusion and dislodgement. Bile leakage can also occur through a well-established tract post internalization of stenting and when the external catheters are removed. Some patients experience external drainage and it is expected to see the skin site and tract close within days after removal. Internal or external leakage can also occur due to traversal of a bile duct before the accessed duct. This leads to the drain going through a bile duct prior to the accessed duct leading to leakage. This is rarely seen when using ultrasound. In severe cases, this may require reaccessing the biliary system using the prior access to guide the access. External bile leakage : External bile leakage could be from catheter clogging or kinking causing biliary dilation and excess pressure leading to back flow of bile and therefore leaking out the tract to the skin. Exchanging the catheter for a larger one to prevent clogging from debris may be needed. A subcutaneous fluid collection could be seen in this scenario. This would typically require drainage of the superficial collection and control of the tract leakage with possible replacement of a biliary drain catheter to control the tract leakage until a final plan is determined. For persistent occlusion and leaking where catheter upsizing is no longer possible, consider wound consultation for placement of an ostomy device over the catheter to protect the skin and to contain and quantify the leak. Antibiotics may be necessary to control early infection. Internal bile leakage : In newer placements and patients who may have ascites or an underdeveloped tract (from skin to bile duct puncture), bile can leak into the peritoneum and can cause bile peritonitis. This can be painful and accompanied by fever and bacteremia. Hence, preexisting ascites should be considered a relative contraindication to placing a percutaneous transhepatic biliary drainage (PTBD). Regular removal of the ascites via paracentesis is recommended. Persistent bilious ascites despite multiple paracentesis should prompt imaging evaluations such as cholangiography to assess for source of biliary leakage. There is a significantly higher risk of complications (>10%) in patients with ascites following percutaneous biliary procedures than in patients without ascites. 7 Skin Side Effects The skin can be affected in many ways that is extremely limiting for patients. A simple suture holding the tube in the wrong position could be painful and bothersome. Sutures are useful in some instances when considering if a tube has moved or been dislodged. When a patient arrives at your department from an outside hospital, evaluation of the skin and sutures around the drain should be performed. Bile is especially toxic to the skin. Skin redness or breakdown from bile leakage can be seen if ongoing and not addressed. Almost all skin-related issues are easily manageable and overcome with medicated creams. In some rare cases when the leakage cannot be controlled with more invasive measures, a barrier cream could be used to help protect the skin. Cutting the sutures and/or not placing them at the time of tube insertion or replacement can be a better option if a good securement device is utilized. Pain Recognizing the different types of pain that can occur can give you an idea if site evaluation would suffice or if cross-sectional imaging/fluoroscopic drain check is needed. Pain can happen for a variety of reasons relating to biliary drains. Intercostal pain can be present when the drain rests on the intercostal nerve and causes continued pain in that location exacerbated by breathing. An intercostal nerve block (using long-acting local anesthetics such as bupivacaine) can be considered to rule out nerve pain and could alleviate long-term pain. 8 However, if pain persists despite multiple attempts to alleviate it, relocating the catheter may be the only option. Deep pain could be seen and should be evaluated with clinical symptoms like fevers, chills, bloating, and output from the drain. In cases where a biliary/gallbladder drain has become dislodged inside the abdomen, pain could be related to bile buildup. Biliary drains can get malpositioned and not drain appropriately. Drain exchange in most cases can resolve pain related to catheter malposition. Cross-sectional imaging can be obtained to rule out etiologies such as bilomas and abscesses. Dehydration Bile is a very important part of the digestive system. Surgery often stresses the importance of dehydration and electrolyte imbalances in relation to fluid and bile salt loss. When patients have external biliary drains and internal–external drains that drain bile in large quantities, it is important to emphasize the need to replace fluid and electrolytes. 9 When a patient has an exclusively external biliary drain, it is important to stress the importance of fluid replacement. With internal–external biliary drains the bile replacement has proven to be effective in restoring the intestinal barrier function. 10 Capping internal–external biliary drains should also be considered. Psychological Issues Drains are constant reminders of patient's disease. In addition to the complications listed earlier, having a drain (or multiple drains) coming out of the skin and attached to bags can limit patient activity significantly. Every attempt should be made to do the following to improve quality of life: Remove drains whenever clinically possible. Internalize (stent) when appropriate. Strongly consider rendezvous procedures (with GI) to limit drain placement. Cap the drain when clinically appropriate to limit “extra baggage.” Vascular Injury Patients with known coagulopathy histories are at high risk for postprocedure bleeding. Central access (close to main segmental/lobar biliary ducts) should be avoided. If central access is needed to opacify the bile ducts for a peripheral fluoroscopic-guided access, the smallest catheter to do so should be utilized. Arterial Injury A hepatic arterial pseudoaneurysm can be seen when biliary access is through an artery ( Fig. 2 ). This can cause pain and bleeding into the bag. A hemoglobin drop may also occur. This is usually managed with angiography and embolization. It is strongly recommended to perform angiography after removing the drain over a wire (to maintain access) if initial angiography does not demonstrate an arterial abnormality. The drain sometimes tamponades the bleed. Hemobilia can present as upper or lower gastrointestinal bleeding ( Fig. 3 ). Angiography and embolization are the treatment of choice. If a major hepatic arterial branch is involved, stent grafting should be considered. Perihepatic hematoma can also be seen in patients with arterial injury and may need angiography and embolization. Subcapsular hematomas are usually self-limiting. These are often seen at the catheter entrance site and can cause pain. This could be contributed to multiple sticks with access and difficulty of getting access. Taking an intercostal approach can cause the intercostal artery to be inadvertently traversed. This can present as a hemothorax . Venous bleeding is usually limited by tamponading effects of the catheter. Intercostal arterial bleeding often necessitates angiography with transarterial embolization. Bleeding can also occur if the catheter is through an abdominal wall artery or vein when gaining the percutaneous access. Typically, the crossed vessels are smaller and the catheter can have a tamponading effect. Abdominal wall hematomas may need angiography/embolization in rare cases. Vascular complications have been reported in 3 to 26% of cases. 11 Bleeding has been known to occur with traversing tumor lesions unintentionally. This is managed with angiography and embolization. Venous Injury A biliary portal fistula is extremely rare. 12 This can be seen if access is obtained through the portal vein ( Fig. 4 ). Presentation of venous bleeding can be completely benign or could include blood in the drain bag. Patients can also present with melena post drain placement and be confused for gastrointestinal bleeding. When evaluation is done for bleeding and post PTBD, looking at the bilirubin levels (direct/conjugated bilirubin) is important and can indicate bilhemia. Movement can cause the side holes to track into the vessel that the catheter has traversed and blood can leak into the biliary tract or bile can leak into the bloodstream. 13 This can cause bacteremia. In some cases, if the portal vein being traversed is small, upsizing can cause scarring and healing. When there is continued bilhemia and elevated bilirubin, catheter evaluation (pull-back sheath cholangiography/tractography) is warranted and possible relocation of the catheter should be considered. Infectious/Inflammatory Complications Cholangitis/Sepsis All patients requiring biliary drain placements and exchanges receive antibiotic coverage in our institution to avoid bacteremia/sepsis due to manipulation. Patients with existing cholangitis requiring biliary decompression require prolonged antibiotic coverage. Despite IV antibiotic coverage periprocedurally, some patients tend to have cholangitic symptoms after routine exchange of the catheter. It is important to decrease pressure in the biliary system while the intervention is being performed: Minimize contrast injection. Keep sheaths open to decrease pressure buildup in the biliary system. Extended course of antibiotics has been beneficial for these cases. In some scenarios where patients are very ill requiring decompression, they may suffer from septic shock post drain placement secondary to biliary infection from prolonged cholestasis. Patients with immediate rigors may benefit from Demerol. ICU admission and management may be needed. Acute Pancreatitis Acute pancreatitis following PTC post PTBD is rare. It can be seen with biliary drainage across an ampullary lesion with internal–external drainage. This is likely due to manipulation of the ampulla which has bacterial contamination. 14 This is also seen with stenting. With external drainage alone, no reported cases of acute pancreatitis have been noted. Patients with acute pancreatitis have unrelenting abdominal pain and should be managed with fluids and pain medications clinically. Biloma/Hepatic Abscess Bilomas can occur from iatrogenic bile duct disruption or from where there is persistent pressure in bile ducts from catheter obstruction. Bilomas, if left untreated, can turn into a hepatic abscess. Bilomas and/or hepatic abscesses are usually accompanied by abdominal pain, fevers, or abnormal liver function tests and are usually assessed by imaging prior to consideration of catheter drainage. If the patient is not systemically sick, and size of biloma or hepatic abscess is too small for catheter drainage, IV antibiotics can be considered with close imaging follow-up. Miscellaneous Complications Bile Duct Perforation/Injury Bile duct injuries can inadvertently occur during any procedure while trying to access the biliary system. Bile duct perforation/injury encompasses injury anywhere along the cystic, right/left hepatic, common hepatic, and common bile duct. The Strasberg classification can be used to stratify bile duct injury. This can be seen when trying to pass a wire into the duct followed by serial dilation and aggressive manipulation. 8 If the location of injury is identified intraprocedure, placing a catheter across the defect with close clinical follow-up is recommended. If the bile duct injury is not able to be located, close clinical follow-up and magnetic resonance cholangiopancreatography can demonstrate location of injury. If a catheter is not able to transverse the injury, an endoscopic approach can be considered after consultation with a gastroenterologist. Extrahepatic access of the bile duct can be obtained in complex cases to opacify the biliary system to help with fluoroscopic targeting of the peripheral bile ducts. However, inadvertent drain placement into the extrahepatic biliary system can lead to a high rate of leakage. 8 Bilothorax/Pleural Transgression The bile ducts can be accessed from the right and left side. On the right side it is not uncommon to have a drain that is placed through lower intercostal spaces. Intercostal access of the biliary ducts can traverse the pleural costophrenic angle space leading to traversing the pleural space. This is usually seen with high intercostal access points on the right side. This can lead to pneumothorax, hemothorax, bile in the pleural space, and empyema ( Fig. 5 ). If possible, consider staying below the 10th rib and anterior to midaxillary line. If there is already an associated pleural effusion at the time of the biliary procedure, and it is clear that a transpleural approach is unavoidable, a chest tube can be considered at the same time of the biliary procedure and pleural fluid be sent for analysis. If output is minimal and cultures are negative within 48 hours, the chest tube can then be removed. If the patient develops an effusion post procedure, diagnostic and therapeutic thoracentesis with or without a chest tube can be performed to exclude bile seeding (high bilirubin) of pleural space. Hemothorax may require intercostal angiography with embolization. Hemothorax and pneumothorax may both need emergent chest tube placement. Bowel Injury Traversing bowel is a real risk with difficult access. Accessing low on the right side of the liver can risk going through a portion of the bowel. The bowel can be tucked up high between the abdominal wall and the liver. At the time of access, the bowel could decompress making it difficult to see the loop in the field of view on ultrasound. On fluoroscopy, the bowel may not be seen at all if doing a blind stick for bile duct access ( Fig. 6 ). Prevention: Consider cone beam CT imaging if available to rule out access across bowel or possibility of access to bowel. If recent imaging suggests excess stool in the gastrointestinal tract, an enema or laxatives could be considered for decompression. Recognition: Stool output may be seen around the catheter. Leukocytosis with peritonitic symptoms may suggest bowel injury. Pain and induration could be seen around the drain site. Management: Traversal of the stomach and small bowel can be managed conservatively. Patients should be monitored closely for development of peritonitis. Traversal of the colon should be treated. This could be repaired using a combination IR–gastroenterology approach and closure of the colonic defects with colonoscopy clips. If this is not possible, surgery may be needed. Vasovagal Reactions Vasovagal reaction is a common complication that can occur at any point during the IR procedure. It is an abnormal reflex reaction to procedure-related triggers that involves increased activation of the parasympathetic nervous system leading to bradycardia, vasodilatation with resultant decrease in cardiac output, and hypotension. Triggers may vary widely from each patient which can range from emotional triggers, fear of pain, to physiologic stressors that can lead to vasovagal syncope. Vasovagal syncope is caused by diminished blood flow to the brain and is usually preceded by a constellation of symptoms of lightheadedness, nausea, pallor, weakness, diaphoresis, and palpitations. Early recognition of a vasovagal reaction may prevent progression to vasovagal syncope which in rare cases can lead to asystole. Management involves mitigating periprocedural stressors and/or halting the procedure with placement of the patient in Trendelenburg position with elevation of legs above the heart and/or IV fluids. 15 For symptomatic bradycardia, atropine 0.5 mg IV slow infusion every 3 to 5 minutes up to 3 mg can be utilized. For persistent symptoms, consider cardiology consultation for further IV administration of inotropic agents such as dopamine or epinephrine. This can be prevented by performing PTC and biliary drains with anesthesia. Tract Seeding/Peritoneal Seeding Presurgical PTBD is performed for biliary decompression in patients with malignant biliary obstruction from cholangiocarcinoma and pancreatic cancer which has been shown to decrease perioperative mortality and morbidity. 16 17 PTBD may also be utilized for palliation for patients who are not candidates for surgical resection. Although tract and/or peritoneal seeding is not a common complication, its description in literature review implores the interventional radiologist to be conscious of ways to mitigate risks for cancer seeding in the tract or peritoneum. 18 19 20 Prevention: The decision to proceed with PTBD should be a result of careful consultation between IR, endoscopic, oncologic, and surgical experts. A left-side approach avoids structures (such as diaphragm and pleura) which are felt to be an ideal environment for seeding. 21 22 Recognition: Tract seeding can be recognized by cutaneous lesions visible at the site of catheter placement or seen on follow-up imaging. Peritoneal seeding can be visible on imaging by CT, magnetic resonance imaging [MRI], or positron emission tomography (PET). The presence of both can be confirmed by biopsy. PET CT is an imaging modality that can be utilized to assess for malignancy persistence or recurrence. Management: Surgical resection as well as systemic chemotherapy can be considered. 23 Biliary Stents Complications and Management of Complications The biliary stents have been routinely classified as plastic and metal stents. The median patency of plastic biliary stents is approximately 2 months. Metal stents include uncovered and covered metal stents. Table 2 outlines complications of covered and uncovered biliary stents. In summary, uncovered metal stents migrate more often. However, stents such as Viabil (Gore, Newark, DE) now have phalanges that allow for stability. Table 2. Complication risk based on type of metal stents. | Covered metal stents ( n = 323) | Uncovered metal stents ( n = 106) | p -Value | | |---|---|---|---| | Occlusion | 82 (25%) | 51 (48%) | p < 0.0001 | | Migration | 41 (13%) | 0 | p < 0.0001 | | Cholecystitis | 17 (5%) | 2 (2%) | Not Significant | | Pancreatitis | 16 (5%) | 4 (4%) | Not Significant | Occlusion Pancreatitis : Stents covering pancreatic ducts can lead to pancreatitis. Cholecystitis : Stents covering the cystic duct could lead to acute cholecystitis. Cholangitis/Sepsis : Manage conservatively as reported earlier. In some cases, when a stent is occluding flow from hepatic segment(s), repeat percutaneous biliary drainage may be needed. Biliary obstruction : Can be from bile sludge incrustation in the stent. This may require repeat percutaneous or endoscopic biliary drainage. Relining the stent may be needed. Tumor ingrowth : This can be seen through the interstices of the stent (uncovered) or at the proximal and distal ends of the stent. 24 This is often seen in cholangiocarcinoma. Migration Stent migration has been known to happen. Treatment of stent migration is retrieval or to push the stent and allow it to pass. The newer stents listed above are made especially (with phalanges) in these cases to help avoid migration. Percutaneous Cholecystostomy Complications and Management of Complications Complications commonly associated with cholecystostomy are similar issues as with PTBDs. These include bile leak, bleeding, infection, and catheter-related complications like obstruction, migration, dislodgement, and fracture and are all listed earlier for discussion and management. Bile leaks and bile peritonitis occur more frequently with free wall versus transhepatic percutaneous cholecystostomies. As with any IR drain, every effort should be made to remove the drain to improve the quality of life for the patient. Percutaneous Transhepatic Cholangioscopic Lithotripsy Complications and Management of Complications Dropped Gallstones Dropped gallstones are not well documented for percutaneous cholangioscopic lithotripsy. This is known to be more of a surgical complication following cholecystectomy. This can lead to recurrent abscesses until the stone is located and surgically removed. As IR explores stone management for cholelithiasis and choledocholithiasis, small fragments could possibly fall/slip out at the time of lithotripsy. Prevention: The principal means in the prevention of dropped gallstones is to assess the need for repeated cannulation of the biliary system risking perforation. The incidence of recurrent biliary stones is high and multiple procedures may be necessary; so, careful patient selection as well as a collaborative team approach should be utilized to minimize complications. Appropriate time (at least 4–6 weeks) should be given for tract formation (skin to bile duct/gallbladder access). This allows for stones/fragments to flow out through the tract instead of getting lodged in the peritoneum/muscles/subcutaneous tissue. Recognition: The most frequently encountered complication from dropped gallstones are the formation of abscesses which are associated with intraprocedural bile spillage. Complications typically stem from their mobile nature which can affect a diverse range of organ systems from pleural lithiasis to colonic fistula formation. The diagnosis of dropped gallstone(s) if not identified early in the periprocedural period may require multiple imaging modalities (ultrasound, CT, or MRI) to identify based on their size and composition. Careful review of patient's procedural history is needed (recurrent abscesses of unknown etiology may assist in making this diagnosis). Management: Abscesses that are accessible percutaneously may be managed with antibiotics and drainage. A small fluid sample should be sent for Gram stain, anaerobic, and aerobic culture with sensitivities to narrow antibiotic treatment to cover the offending organism. Abscessograms can be performed with output less than 10 mL per day to exclude fistulous communication to surrounding organ systems prior to catheter removal. For nonhealing fistulas, consider expert consultation based on anatomic location. Percutaneous removal of retained gallstones can also be attempted. There is no general consensus on the management of asymptomatic dropped gallstones as the incidence of complications is low. 15 25 It is prudent to inform the patient and document in the medical record that dropped gallstones are there. They may be mistaken for focal masses, endometriosis, or peritoneal deposits from neoplastic sources on future imaging studies. For high-risk elderly patients, with sepsis, documented intraprocedural bile spillage, or with multiple comorbidities, follow-up should be determined by the interventional radiologist and communicated with the primary care physician. Gallbladder/Bile Duct Perforation This can be seen depending on the type of instrument to break down the stones. Stiff rigid instruments can cause blunt perforation. Lithotripsy instruments can lead to gallbladder and bile duct wall perforation. However, the risk of bile duct and gallbladder wall perforation is low when lithotripsy is done with direct visualization using endoscopy. Pancreatitis PTC and percutaneous cholecystostomy have a negligible rate of acute pancreatitis when compared with endoscopic retrograde cholangiopancreatography. However, as interventional radiologist gets comfortable with lithotripsy, it is very important to know that stones/stone fragments can get lodged in the ampulla and lead to acute pancreatitis. Leaving drains/stents across the ampulla from the biliary system to minimize this risk in the immediate postlithotripsy period is recommended. Percutaneous Transjejunal Access Complications and Management of Complications Percutaneous transjejunal biliary access is performed mostly in post–liver transplant with a history of primary sclerosing cholangitis or in other liver surgical resections. A limb of the Roux-en-Y is tacked to the abdominal wall with surgical clips (in most cases) as a stoma referred as a modified Hutson loop for repeated radiologic access when patients may have multiple areas of stenosis requiring repeat interventions or stone retrieval. 26 27 Since there is no transhepatic access, some of the above bleeding/vascular complications are not as common. These patients are not good candidates for endoscopic approach, given the surgical variant with Roux-en-Y hepaticojejunostomy anatomy. Peritonitis/Abscess Prevention: Complications can come from access with the stoma through the modified Hutson loop. Knowing exactly where to access the jejunum if there are no surgical clips can help avoid access site complications. Manipulation at the stoma with catheters larger than 14 Fr can cause tearing or break down of the surgical stoma leading to leakage resulting in peritonitis. Also, this manipulation at the stoma site can be associated with leakage from the bowel to the abdominal skin tissues leading to superficial abscess. It is also essential when placing plastic stents that the plastic stent tip remains in the bowel and not protruding through the bowel into the subcutaneous tissue. Recognition: Superficial leakage is noted in follow-up evaluation with abdominal distention, pain, and persistent leakage from the site after instruments have been removed ( Fig. 7 ). Recognizing if patients are having early infections and taking temperatures to catch sepsis early can help avoid hospital admissions. Management: Patients with peritonitis would require supportive care and likely result in extended hospital courses and antibiotic coverage. If there is a subcutaneous abscess, percutaneous drainage is required. Drain placement in the modified Hutson loop to control external leakage until the surrounding site can heal may be required. In severe cases, PTBD may be required to divert bile externally.

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