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 .