Biliary tract interventions

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  • biliary tract interventionsTHORSANG CHAYOVAN/AJ.K IT TIPITCH BANNANGKUN

    INTERVENTIONAL RADIOLOGY, PRINCE OF SONGKLA UNIVERSITY

    18.11.2015

    Topic in Interventional Radiology

  • Percutaneous transhepatic biliary drainage

  • Biliary tract obstructionBenign causes of biliary obstruction are often iatrogenic in nature Biliary tree injury during surgical procedures

    Others: trauma, inflammatory processes (stone disease or pancreatitis), sphincter of Oddi dysfunction, and a late complication of intraabdominalprocesses

    Malignant biliary strictures are much more common Cholangiocarcinoma, gallbladder and pancreas cancer

    Lymphoma and metastasis Hepatocellular carcinoma

  • Percutaneous TranshepaticCholangiography (PTC)Introduced clinically in the 1970s

    Popular in the 1980s-early 1990s

    ERCP has largely replaced PTC in the diagnosis and treatment of biliary tract obstruction

    However, PTC still has an important role in the management of patients with biliary tract disease

  • Current role of PTCPTC often when endoscopic techniques are not possible Hilar obstruction

    Surgically altered anatomy When ERCP is technically unsuccessful

    When additional information about the intrahepatic extent of disease is desired

    Careful patient selection

    Review of preprocedural diagnostic imaging studies

    Appropriate planning

  • Indications for PTC and PTBD Biliary obstruction

    With failed endoscopy in patients with obstructive jaundice or sepsis/cholangitis

    With biliary-enteric anastomoses Following surgical procedures with ductal transection/ligation

    Access for the percutaneous treatment of biliary stone disease

    Biliary stent placement Palliation

  • Relative contraindications Uncorrectable coagulopathy: INR 1.5 or less

    Platelet at least 50,000 (PSU 80,000)

    Platelet transfusion in patients taking aspirin and clopidogrel may be helpful

    History of allergy to iodinated contrast agents

    Large volume ascites

    Lack of a safe percutaneous access route to the biliary tree

  • Contraindications for PTBD

    Segmental high bile duct obstruction

    Multiple isolations

  • Contraindications for biliary stent placement

    Candidate for surgery

    Benign disease

    Sepsis

  • Patient Selectionand Preparation

  • Preprocedural Imaging Typically consists US followed by either CT or MRI +/- MRCP

    Etiology of the obstruction

    Procedural planning

    >> Careful review before the procedure Determine the best approach

    Consider potential pitfalls

    Variations in biliary tract anatomy

  • Initial Access

    Right-sided Left-sided

  • Parenchymal AtrophyCause: long-standing biliary and/or portal venous obstruction

    Characteristics: dilated bile ducts that are crowded together

    Drainage is unlikely to recover liver function

    Avoid them!

  • Portal Vein Status

    Only liver segments with patent portal venous supply should be targeted during biliary drainage

  • Preprocedural Preparation: LabsINR 1.5 or less

    Platelet count of at least 50,000/dL (PSU 80,000/dL)

    Normal PTT

    Elevated INR Vitamin K--elective procedure that can be delayed until the coagulations normalize

    Fresh frozen plasma--urgent or emergent evaluation

    Low platelet count Platelet transfusions

  • Preprocedural PreparationHydration

    Prophylactic antibiotics Transient bacteremia--to minimize the risk of sepsis or abscess formation

    Patients with biliary-enteric anastomoses/dysfunctional sphincter of Oddi(sphincterotomy or endoscopic stent placement)

    More susceptible to infectious complications secondary to colonization of the biliary tree and infection of the bile

    Ampicillin-gentamicin, piperacillin/tazobactam, ampicillin/sulbactum, or a fluoroquinolone (ciprofloxacin or Levaquin)

  • Sedation and analgesia Elective: moderate sedation Narcotics (fentanyl citrate) and benzodiazepines (midazolam or

    diazepam) +/- meperidine Clear liquid diet for a minimum of 2 hours before the procedure

    Urgent or emergent intervention Hemodynamic instability making procedural management more

    complicated Monitoring or sedation by an anesthesiologist may be necessary

  • Patient PreparationA supine or a slight RAO position, preferably with the arm elevated above the head or extended to the side allow wide access to the right hepatic lobe

    US Help to determine the optimal route for access of the biliary tree

    Skin sterilized and draped

    Sedation agents should be given before attempting to access the biliary system Patient comfort Cephalad migration of the liver may occur because of decreased tidal volumes

  • Technique

    Choose the access route

    Lidocaine to the skin, subcutaneous tissues, and the hepatic capsule

  • Right-sided Access

    Identify the inferior aspect of the right lobe A low intercostal approach near midaxillary line

    At or below the superior margin of the 11th rib

    Have the patient take several deep breaths under fluoroscopy Avoidance of pleural transgression during access

  • Right-sided Access A 22-gauge Chiba needle is introduced and directed toward the contralateral shoulder

    When reach the liver hilum, slowly withdraw while simultaneously injecting contrast gently Avoid parenchymal staining (which may obscure adjacent anatomy)

    Flow like dripping wax and outline the tubular-shaped ducts

  • Left-sided AccessA short needle Left lobe biliary ducts are anterior and close to the anterior abdominal wall

    US may be used to identify an enlarged duct and provide guidance for initial needle placement

    The needle is inserted just lateral to the xiphoid at the costal margin

  • Initial Access

    Aspirate a small amount of bile for microscopy and culture

    Do not overinject the biliary system, particularly in the presence of obstruction Possibility of inducing sepsis

  • After needle access Adequate opacification of the ductal system

    Select a suitable duct Inferior ducts are preferred

    For avoidance of pleural transgression, especially on the right

    Relatively straight course toward the hilum Facilitate the passage of a guidewire and catheter

    Access the duct peripherally Decrease the chance of injury to the larger vascular structures near the

    hilum

  • 1-stick technique

    A 0.018- inch wire can be introduced

    Wire advanced needle removed dilator replaced

    Extreme care passing dilators over a guidewire One should advance the dilator under fluoroscopy

  • 1-stick technique

    0.018-inch stiffer 0.038-inch wire Most are a triaxial design

  • 2-stick technique May be used if the initial access needle placement is suboptimal Tip position overly central or within an excessively small/tortuous duct

    The initial needle access (the first-stick) to the biliary system Permitting continuous opacification of the bile ducts

    Following opacification of the ductal system, choose an optimal duct to access with the second needle

  • After gaining access into the biliary tree Place a sheath into the duct Maintain secure access

    Facilitate the passage of any catheters and guidewires

    Attempt to cross the area of obstruction and ultimately gain access through the ampulla into the duodenum through the biliary tree

    Avoid creating a dissection within a bile duct

  • Drainage catheter

    INTERNAL-EXTERNAL

    Allows bile to drain externally into a bag

    internally into the small bowel

    Preserving the normal enterohepatic circulation of bile

    EXTERNAL

    Unable to advance a catheter through an obstruction and into the duodenum

  • Drainage catheter 8 to 14 Fr with multiple side holes

    A radiopaque marker proximal extent of the side holes

    A pigtail distal/internal end of the catheter with a locking mechanism to maintain the position in bowel/ducts

    In position which the side holes will drain all the intrahepatic ducts

    Confirmed with contrast injection

    If there are any ducts that are not adequately drained, placement of a second catheter may be required

  • Postprocedural Management Routine postsedation monitoring for 2-3 hours

    Hospital admission in intensive care unit

    Beware of sepsis and/or hemorrhage

    Antibiotics should be continued and adjusted according to results of the Gram stain and cultures Escherichia coli, enterococci, Klebsiella species, and Streptococcus viridans

  • Postprocedural Management Postprocedural pain control Discomfort, particularly if the route of access was via an intercostal space

    Pain will gradually decrease over 24-48 hours

    Use soft drainage catheter

    Catheters should be routinely flushed with 5-10 mL NSS every 8 hours to maintain patency

    Exchange q 3 months (2 months at PSU)

    Prior to removing any biliary drainage catheter, clamped for 24-48 hours Assessment of the adequacy of internal drainage

  • ComplicationsInfection and sepsis* Prophylactic periprocedural antibiotics

    Hepatic abscesses Several weeks after

    May need catheter-directed drainage and a prolonged course of antibiotics

  • ComplicationsBile leakage Increased risk if

    Catheter becomes occluded or dislodged

    Catheter side holes extend beyond the liver

    If bile peritonitis develops, one must drain any intraperitoneal collection

    Routine catheter exchanges are performe