bile leakage is a well - known and dreaded complication of open or laparoscopic cholecystectomy ( lc ) , major liver surgery , and blunt abdominal injury . with the advent of treatment by endoscopic sphincterotomy and drainage using either an endoprosthesis or nasobiliary catheter ,
surgery is now avoided in the majority of cases.[27 ] however , up to 10% of patients with biliary leaks after lc do not respond to initial endoscopic therapy .
those with more severe ductal injury and large leaks are especially likely to require surgery . in the past few years , some alternatives to surgery have been used to control bile leakage , such as injection of fibrin and ethanol , but these have their own problems and complications .
nbca is a tissue glue monomer that instantly polymerizes and solidifies upon contact with body fluids at neutral ph .
this substance is routinely used in plastic surgery , radiology , neurosurgery , and general surgery and was first used for obliteration of bleeding gastric varices .
nbca has recently been approved in europe for endoscopic hemostasis and sealing of fistulae ( glubran 2 , gem , viareggio , italy ) . in the literature ,
we would like to discuss one patient where we used nbca to seal a biliary leakage in a patient with a carcinoma of the papilla of vater who did not respond to standard endoscopic drainage methods .
an 83-year - old male with a carcinoma of the papilla of vater was treated with a 10f polyethylene stenting ( olympus , mt waverley , australia ) of the main biliary duct during endoscopic retrograde cholangiopancreatography . when a stent release was attempted , it was not completely released and remained folded ; it was not possible to remove it endoscopically .
so a percutaneous transhepatic cholangiogram was performed through the puncture of right intrahepatic biliary system .
after several cholangiogram controls , stent positioned by endoscopists was removed and two new covered stents ( 9  80 mm ) were deployed ( smart , cordis ; miami lakes , fl ) . an internal drainage was maintained .
the leakage probably originated from the posterior ducts , and it was caused from percutaneous puncture .
conservative treatment was attempted , with maintenance of internal drainage for 15 days , but the leakage associated with a biloma persisted internally [ figure 1 ] .
the patient had pain , fever , and elevated inflammatory indices . using a different percutaneous access , through the right lobe itself , a superselective approach to the site of the leakage was obtained , using another biliary radicle , which was dilated enough .
a 2.8f microcatheter ( progreat ; terumo , tokyo , japan ) was used using a 5f catheter ( cobra , cordis , miami lakes , fl ) and an hydrophilic guidewire ( terumo , tokyo , japan ) .
embolization was performed with three fibered 0.018-inch platinum micro - coils ( vortx ; boston scientific ) with nominal configured diameters of 2 mm  3 mm , pushed with saline solution injection .
the microcatheter was preliminary flushed by a nonionic dextrose solution and then the tissue adhesive agent nbca ( glubran 2 , gem ) , mixed with iodized oil ( lipiodol ; guebert , aulnay - sous - bois , france ) in a ratio of 1:2 for opacification , was injected [ figure 2 ] .
a postprocedural cholangiogram confirmed the absence of any complication and the disappearance of the leakage [ figure 3 ] .
external biliary drain open , allowing bile drainage and permitting easy access for repeat radiologic follow - up . at the last follow - up visit ( 3 months after the procedure ) , the drainage was removed , and no evidence of recurrence was noticed [ figure 4 ] , and also biloma was reabsorbed .
cholangiogram shows biliary leakage ( arrows ) after conservative treatment superselective embolization of biliary leakage with nbca ( arrows ) postprocedural cholangiogram shows the disappearance of the leakage ( arrows ) cholangiogram performed after 3 months shows the absence of recurrence .
the drainage was removed informed consent was obtained before each procedure . before any percutaneous procedure , the patient receives intravenous antibiotic , 1.5 g cefuroxime ( cefurex , salus researches s.p.a , italy ) , as a one - time dose .
biliary leakage occurs most frequently after hepatobiliary surgery , especially open or lc , but is also seen after liver resection or liver transplantation , after endoscopic or interventional radiological maneuvers , or after severe hepatic trauma .
many of these biliary tract injuries may go unrecognized at the time of surgery and have a delayed presentation .
nonoperative management of these patients can be successful , and interventional radiology has a major role to play in delineating the anatomy of the injury and controlling ongoing bile duct injury . in the literature , there is a description of the use of fibrin glue for the treatment of communication between an abscess cavity and an aberrant posterior segment hepatic duct that was injured in a lc ; however , the bile discharge in that case was not reduced and the cavity and fistula could not be closed .
there are three main materials that have been studied as potential sealants of the biliary tract : fibrin , ethanol , and nbca .
matsumoto et al . reported a case in which multiple ethanol injections were performed to close a biliary - cutaneous fistula from an isolated small bile duct of the left caudate lobe after resection of the right caudate lobe for hepatocellular carcinoma .
sadakari et al . described a case of intractable bile leakage after hepatectomy , which was successfully treated by percutaneous transhepatic portal embolization with ethanol .
ethanol is not advised when there is communication with the remainder of the biliary tree as there may be seepage of the ethanol into the biliary tree , which could lead to irreversible damage .
flushing , fever , leukocytosis , mild increases of aminotransferase levels , and systemic hypotension may occur with ethanol injection .
ncba , a low - viscosity monomer used as tissue adhesive glue , is a promising solution to biliary chemical embolization .
when in contact with organic fluids ( i.e. , bile ) , this substance undergoes rapid polymerization and solidification .
it provides a permanent embolization and hence , due to an inflammatory tissue response , a long - term occlusion in vessels of various size resulting in vessel thrombosis or tissue atrophy .
vu et al . , based on their experience with six patients , suggested the placement of a coil at the neck of the fistula and subsequent administration of nbca from an external approach as the most effective way to prevent recurrence of biliary fistulas .
described their experience of percutaneous embolization of bile duct fistulas with ethibloc ( ethicon , somerville , nj ) and isobutyl-2-cyanoacrylate in four patients .
they observed unintentional spillage of isobutyl-2-cyanoacrylate in the bile duct in one of the four patients .
they also reported that a coaxial catheter became glued to the bile duct wall in one patient after an isobutyl-2-cyanoacrylate embolization .
if the patient is unable to undergo percutaneous embolization for the biliary leak , continued percutaneous drainage is also an option .
bleeding episodes can occur after catheter removal and metabolic acidosis may develop secondary to continued bile loss from the drainage catheter .
we could find only two reports in literature describing biliary leakage treated with percutaneous insertion of nbca : the series of patients ( six patients ) treated by vu et al . and a case report by lauterio et al .
the success of the procedure in our patient is further evidence of the efficacy and safety of using percutaneous insertion of nbca glue in biliary injuries .
further studies are needed to confirm the efficacy and safety of this approach and to determine whether it can reduce hospital stay and treatment costs .
 biliary leakage is a known complication after biliary surgery . in this report 
 , we describe an uncommon treatment of a common biliary complication , wherein we used percutaneous transhepatic injection of n - butyl cyanoacrylate ( nbca ) to treat a biliary leak in an 83-year - old patient . 
Introduction
Case Report
Discussion