An iatrogenic hepatic subcapsular biloma successfully treated by percutaneous drainage and endoscopic biliary stenting.

with complaints of appetite loss and ab− dominal pain. Abdominal computed to− mography demonstrated a tumor of the gallbladder and dilatation of intrahepatic bile ducts. Although he was not jaun− diced, he was suspected to have a malig− nant hilar biliary stricture, and percuta− neous transhepatic cholangiography was performed on the right lobe of the liver with placement of a drainage catheter (l" Fig. 1). Cytological examination of the bile revealed adenocarcinoma. Unfortunately, 5 days after the catheter was placed it was accidentally removed and the patient was referred to our hospi− tal. Abdominal computed tomography and magnetic resonance imaging showed a diffuse hepatic subcapsular fluid collec− tion, which was considered to be an iatro− genic biloma (l" Fig. 2, 3). A percutaneous catheter was placed in the biloma under ultrasound and fluoroscopic guidance. Because abdominal computed tomog− raphy had revealed multiple nodules in the peritoneum, the patient was diag− nosed with unresectable gallbladder car− cinoma due to peritonitis carcinomatosa. Endoscopic retrograde cholangiographic examinations showed a Bismuth type IIIa hilar biliary stricture (l" Fig. 4 a). We then performed a three−branched partial stent−in−stent deployment using JoStent SelfX stents (Abbott Vascular Devices, Redwood City, California, USA) (l" Fig. 4 b) [1]. Once the metallic biliary stents were in place, abdominal comput− ed tomography showed marked resolu− tion of the biloma, and the percutaneous drainage catheter was then removed (l" Fig. 5) and the patient was treated with gemcitabine chemotherapy. Biloma, defined as an encapsulated col− lection of bile outwith the biliary tree, oc− curs secondary to traumatic or iatrogenic injury in most cases [2]. It has been re− ported that bilomas can be treated by percutaneous catheter drainage and/or endoprosthesis placement [3,4]. Particu− larly useful in patients with malignant biliary obstruction, the deployment of metallic biliary stents can also facilitate closure of the intrahepatic biliary duct in− jury that caused the biloma.