You are in: eMedicine Specialties > Radiology > VASCULAR/INTERVENTIONAL Biliary Tract, Percutaneous InterventionArticle Last Updated: Jun 7, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 8
  Author: Atif Rana, MBBS, Assistant Professor, Department of Radiology, Section of Interventional Radiology, University of Alabama at Birmingham Atif Rana is a member of the following medical societies: Radiological Society of North America and Society of Cardiovascular and Interventional Radiology Editors: Gary P Siskin, MD, Associate Professor, Department of Radiology, Albany Medical College; Chief, Division of Vascular and Interventional Radiology, Department of Radiology, Albany Medical Center; Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Douglas M Coldwell, MD, PhD, Professor of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; Kyung J Cho, MD, FACR, William Martel Professor of Radiology, Fellowship Program Director, Department of Radiology, Division of Interventional Radiology, University of Michigan Medical School Author and Editor Disclosure Synonyms and related keywords: biliary interventions, percutaneous cholangiography, percutaneous transhepatic cholangiography, PTC, percutaneous biliary drainage, PBD, biliary stenting, biliary stent placement, percutaneous cholecystostomy, endoscopic retrograde cholangiopancreatography, ERCP PERCUTANEOUS BILIARY INTERVENTIONSSection 2 of 8
  Over the past few decades, biliary interventions have evolved a great deal. Opacification of the biliary system was first reported in 1921 with direct puncture of the gallbladder. Subsequent reports described direct percutaneous biliary puncture. The technique was revolutionized in 1960s with the introduction of fine-gauge (22- to 23-gauge) needles. During the 1970s, percutaneous biliary drainage (PBD) for obstructive jaundice and percutaneous treatment of stone disease was introduced. Percutaneous cholecystostomy was first described in the 1980s. With the advent of metallic and plastic internal stents, further applications in the treatment of biliary diseases were developed. Current percutaneous biliary interventions include percutaneous transhepatic cholangiography (PTC) and biliary drainage to manage benign and malignant obstruction, and percutaneous cholecystostomy. Percutaneous treatment of biliary stone disease with or without choledochoscopy is still performed in selected cases. Other applications include cholangioplasty for biliary strictures, biopsy of the biliary duct, and management of complications from laparoscopic cholecystectomy and liver transplantation. PERCUTANEOUS CHOLANGIOGRAPHYSection 3 of 8
Common causes of benign biliary obstruction include bile duct stones, strictures, sclerosing cholangitis, iatrogenic conditions, inflammatory processes (eg, pancreatitis), and infections (eg, HIV infection, oriental and parasitic cholangitises). Common malignant causes of biliary obstruction include carcinoma of pancreas, cholangiocarcinoma, and metastatic disease. Other causes of biliary obstruction include Caroli disease, Mirizzi syndrome, retroperitoneal fibrosis, ampullary carcinoma, and gallbladder carcinoma. The 2 procedures used to evaluate the biliary anatomy are endoscopic retrograde cholangiopancreatography (ERCP) and PTC. ERCP is the first test of choice. PTC is more invasive and painful than ERCP, mainly because the PTC procedure involves puncturing the liver capsule. It also poses the risks of hemoperitoneum and bile peritonitis. PTC is now usually reserved for patients in whom ERCP is unsuccessful when the biliary system cannot be cannulated or when the obstructing lesion prevents contrast material from opacifying the cephalic portions of the biliary system. PTC, however, is the preferred procedure in patients with a history of anatomy-altering surgeries. These include the Billroth II procedure, which involves antrectomy with gastrojejunostomy; this procedure makes using an endoscope to cannulate the ampulla difficult because the endoscope must be passed through the gastrojejunostomy anastomosis and then retrograde towards the duodenum. The failure rate for ERCP in this situation is high, as is the complication rate. In a study by Faylona et al in 1999, successful selective cannulation during ERCP was achieved in only 66% of attempts. Cannulation was accompanied by a bowel perforation rate of 6%. Other indications for PTC include the management of postoperative or posttraumatic bile leakage. Clinical evaluation Initial clinical evaluation of a patient with jaundice and biliary tract disease should include history taking, physical examination, and pertinent laboratory tests. After the initial workup, radiologic examinations are required to determine the cause of biliary obstruction. Ultrasonography, MRI, and CT are the common modalities used for this purpose. Cross-sectional imaging provides information about the pattern of biliary dilatation and the level of obstruction, and it can potentially reveal the cause. Patient preparation The preprocedural workup should include a review of the imaging studies. Pertinent laboratory results are checked, including coagulation parameters, prothrombin time (PT), and activated partial thromboplastin time (aPTT). The hematocrit value, WBC count, platelet count, and liver function results are obtained. Antibiotics are routinely administered before the procedure. Antibiotics are necessary because bacteremia and sepsis can develop during the procedure. Roughly one third of patients with malignant obstruction and two thirds of patients with benign obstruction have infected bile. The antibiotics should cover both gram-negative and gram-positive bacteria. Escherichia coli is the most common organism involved; enterococci, Klebsiella species, and Streptococcus viridans are other common organisms. At the author's institution, cephalosporins are commonly used. In patients with a history of allergic reactions to penicillins and cephalosporins, ciprofloxacin can be used. Technique After the patient is placed in the supine position and after sterile preparation and draping are performed, intravenous sedatives are given. The skin-puncture site is anesthetized with a local anesthetic (2% lidocaine [Xylocaine]), and conscious sedation is needed for adequate pain control. This is achieved by using intravenous midazolam (Versed) and fentanyl (Sublimaze). An intercostal nerve block can also be used if pain control is inadequate. Epidural anesthesia and pleural block are options that can be used for especially painful and lengthy procedures, such as when a drainage procedure or intervention is being performed. General anesthesia may be needed in selected cases. Most PTCs can be performed from the right midaxillary approach, though a subxiphoid approach is occasionally needed. Some patients (eg, those with a cholangiocarcinoma involving the hilum and central right and left hepatic ducts) may require bilateral access. The skin-puncture site is selected by observing the right costophrenic sulcus during deep inspiration. The access point is generally in the midaxillary line in an intercostal space caudal to the costophrenic sulcus. The skin and subcutaneous tissues are anesthetized with local anesthetic. A 21- or 22-gauge needle is then advanced into the liver under fluoroscopic guidance by aiming for the 12th thoracic vertebral body. After the inner stylet is withdrawn, and contrast material is injected while the needle is retracted. Specific flow patterns of the contrast agent are noted. The vessels show opacification that disappears rapidly, whereas the bile ducts show slow opacification. Cholangiography is then performed to delineate the biliary anatomy (see Image 1). In a dilated biliary system, allowing the bile to drain before contrast injection is beneficial because it decreases the risk of inducing bacteremia and sepsis, which can occur because of overdistention of the obstructed biliary system. If the needle enters a bile duct in a position unsuitable for subsequent catheterization, a second needle can be used to puncture the opacified ducts (see Image 2). The left hepatic ducts are anterior in relation to the right lobe ducts; therefore, they may not fill with the patient in the supine position because the contrast agent flows to the more posterior and dependent right ducts. If not already seen, the left hepatic ducts can be opacified by carefully having the patient roll to the left. After the biliary system is completely delineated and images are obtained, the needle can be withdrawn if no further intervention isdeemed necessary. The success rate for PTC is reported to be more than 95% in a dilated biliary system and 67-80% in a nondilated system. Additional needle passes increase the success rate. Complications include sepsis, peritonitis, hemorrhage, and pneumothorax. Pneumothorax is rare and associated with a right-sided approach. To minimize this risk, perform fluoroscopic examination of the right costophrenic sulcus during deep inspiration to evaluate diaphragmatic excursion, and choose a puncture site caudal to the sulcus. PERCUTANEOUS BILIARY DRAINAGESection 4 of 8
Indications In many cases, PTC is followed by the placement of percutaneous biliary catheters for drainage. PBD is needed in many patients. For example, it may be helpful in relieving obstructive symptoms, especially those due to unresectable malignant tumors (see Image 3), as well as in treating those with various types of benign strictures (including postoperative strictures), primary sclerosing cholangitis and liver transplants. Other indications include cholangitis secondary to biliary obstruction, diversion for bile leaks while the patient is awaiting surgery, and transhepatic brachytherapy for cholangiocarcinoma. Technique PTC is performed as described above. Once the needle is in the bile duct, a 0.018-inch wire is advanced. After the wire is passed to a secure position in the biliary tree, the needle is removed. For further interventions, a larger (eg, 0.035- or 0.038-inch) wire is needed. A sheath of the coaxial system can be passed over the 0.018-in. wire, and the inner 2 components (wire and inner coaxial dilator) can then be removed to accept the larger wire. The assembly set, consisting of an outer fluoropolymer sheath (Teflon; DuPont, Wilmington, Del), inner fluoropolymer sheath (Teflon; DuPont), and a metal cannula, is advanced over the wire. The 2 sets in common use are the Accustick introduction system (Meditech/Boston Scientific; Watertown, Mass) and the Neff percutaneous access set (Cook, Inc; Bloomington, Ind). After the tip is in the bile duct, the 2 outer fluoropolymer sheaths are advanced over the wire. Once in position, the inner sheath and stiffener are removed, leaving the outer sheath behind. This outer sheath has a 4F inner diameter and a 4F catheter through which a 0.035- or 0.038-inch wire can be passed. Cholangiography with further injection of contrast agent can be performed at this stage to improve delineation of the level of obstruction. A 4F catheter with a distal curve (eg, Berenstein catheter) and a 0.035-inch hydrophilic guidewire are usually used to cross the obstructing lesion. When the obstruction is high grade and the bile ducts are severely dilated, crossing the obstruction may not be possible. In these cases, external drainage can be tried for a few days to decompress the biliary system, and another attempt can be made later. After the catheter is advanced to the duodenum, the wire is exchanged for a stiff guidewire (eg, Amplatz superstiff wire; Cook, Inc) (see Image 4). The catheter and sheath are removed, and a biliary drainage catheter is advanced. Various biliary drainage catheters are available. Commonly used catheters have a retaining pigtail loop. The end of this catheter is reformed after the catheter tip is in position in the duodenum and after the inner stiffener is removed (see Image 5). The proximal side-hole location is checked by injecting contrast material to ensure that it is in the bile duct and not intraparenchymal, as malpositioning may lead to pericatheter leakage or hemobilia. The internal fixation is achieved by using a loop-retaining suture. Catheters are also secured to skin by using suture material such as 2-0 polypropylene mesh (Prolene; Ethicon; Piscataway, NJ). The catheter should initially be left to external gravity drainage. A cap can be placed after a few days when the bile is clear of blood and when the patient is afebrile. Complications of percutaneous drainage are most frequent in cases of malignant obstruction. In addition to complications of PTC, bile leakage, bilorrhea, hemobilia, cholangitis, hemothorax, and pancreatitis can develop. Patients should be instructed regarding routine catheter care if they are being discharged home after the procedure. The catheter should be flushed with 5-10 mL of sterile water or normal sodium chloride solution at least every 24 hours to prevent debris collection and catheter blockage. Catheters should be exchanged every 3-4 months because they are prone to breakage and occlusion over time. Some authors advocate exchange even more frequent than this. Patients should be instructed to uncap the catheter to set it for external drainage in case of the onset of fever. If fever occurs, further investigation is usually necessary because it is presumed to be due to catheter blockage and resultant cholangitis until proven otherwise. BILIARY STENTINGSection 5 of 8
Stents Internal biliary stents are either plastic or metallic, and various types of each kind are available. Internal biliary stents have several advantages. An external tube can be uncomfortable and have a psychological disadvantage (especially in cases of malignant obstruction). An internal stent prevents the problems related to external catheters, for example, pericatheter leakage of bile and the need for daily flushing. The disadvantages include having to perform ERCP or new PTC procedures to obtain access in case of stent obstruction. Better patency rates are reported with metallic than with plastic stents in cases malignant obstruction, though no effect on survival is noted. Plastic internal stents are cheapest but reportedly prone to migration. Various types of plastic stents in use include the Carey-Coons stent (Percuflex; Meditech/Boston Scientific) and silicone stents (Malecot; Cook, Inc). Metallic stents are generally not used in the treatment of benign disease because studies have shown poor long-term patency rates. Gabelman et al (2001) reported a patency rate of only 25% at 36 months when metallic stents were used to treat benign obstruction. In another study, Lopez et al (2001) found that two thirds of patients had poor clinical results and that one half of these required major surgical intervention. The Gianturco-Rosch Z stent (Cook, Inc), a metallic stent, has been used in benign strictures, but it should not be used for primary treatment. Limited applications may include the treatment of patients who are poor surgical candidates or of those in whom surgical treatment fails. Most postoperative strictures are treated surgically, though endoscopic and (less commonly) percutaneous placement of nonmetallic stents has increasingly been used in the past few years. In cases of malignant obstruction, stents are placed as a palliative measure only if the tumor is unresectable (see Image 6). Various stents are approved for use in the biliary system, including self-expanding and balloon-mounted stents. Kaskarelis et al reported a 98% technical success rate in the treatment of malignant biliary obstruction with metallic stents. They reported an 18% stent occlusion rate at a mean interval of 288 days. Lee et al (1999) showed a 50-week patency rate of 53%. Causes of stent obstruction include tumor ingrowth through the stent, proximal or distal tumor overgrowth, and biliary sludge. Covered stents are now being investigated to overcome the problem of tumor ingrowth. Two recent studies of stents covered with polytetrafluoroethylene–fluorinated ethylene propylene (ePTFE-FEP) stents showed 12-month patency rates of more than 75%. Technique Various self-expanding stents include the Wallstent (Boston Scientific; Natick, Mass), Luminex stent (Bard; Tempe, Ariz), and Smartstent (Cordis Endovascular; Miami, Fla). The stent is usually placed at an interval of a few days after PBD, though in cases of uncomplicated PTC, the stent procedure can be accomplished at the same time. An introducer sheath is passed into the biliary system over a stiff wire. The stent delivery system is then advanced over the wire and the stent is deployed. Balloon dilation is occasionally needed to achieve adequate expansion. In cases of hilar malignancy that causes obstruction of both hepatic ducts, bilateral stents may be needed. PERCUTANEOUS CHOLECYSTOSTOMYSection 6 of 8
Cholecystostomy is used as a temporizing measure in critically ill patients with acute cholecystitis who cannot undergo cholecystectomy. After the symptoms resolve and the patient's condition is stabilized, definite treatment is still gallbladder removal. In acalculous cholecystitis, percutaneous drainage may be the only treatment required. The procedure is performed under ultrasonographic and fluoroscopic guidance, though it can be performed with only ultrasonographic guidance. Most clinicians prefer a transhepatic approach because a transperitoneal approach poses a risk of bile peritonitis. However, a transperitoneal approach can be used if the gallbladder is very distended. The gallbladder can be punctured with a trocar needle-catheter or by using a Seldinger technique. Various catheters in use include the Hawkins accordion catheter and the McGahan catheter; however, an all-purpose pigtail drainage catheter can be used safely. Bile samples are collected for Gram staining and cultures. A small amount of contrast agent is injected to confirm the position of the catheter, and the catheter is secured to skin by using suture material. It is left to drain by gravity. Complications include bile peritonitis, hemobilia, gallbladder perforation, and a vagal effect due to catheter placement. Definitive treatment for calculous cholecystitis is gallbladder removal. If surgery is not considered, as in acalculous cholecystitis, the tube can be removed after signs of infection resolve. The time for tract maturation is not well established. Davis et al (1999) advocate 7-10 days to allow tract maturation, though they do not describe whether tract maturation they evaluated by injecting contrast material. At the author's institution, the cholecystostomy catheter is generally removed after 2-3 weeks. The tube is clamped for about 48 hours to evaluate the patency of the cystic duct and to observe for any signs and symptoms suggestive of cystic duct obstruction. If the patient does not develop any complications, such as fever, pain, or an increasing WBC count, the tube is removed. Tract maturation is evaluated before the catheter is removed by injecting contrast material through the catheter while the catheter is pulled over a wire. If extravasation into the peritoneum is noted, the catheter should be reinserted to prevent bile peritonitis. A follow-up study is performed in a few weeks in a similar fashion to evaluate for tube removal. MULTIMEDIASection 7 of 8
REFERENCESSection 8 of 8
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