Cholangiography of intrahepatic bile ducts in hepatolithiasis by endoscopic placement of an indwelling balloon catheter

0016-5107j85j3103-0181$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1985 by the American Society for Gastrointestinal Endoscopy

Cholangiography of intrahepatic bile ducts in hepatolithiasis by endoscopic placement of an indwelling balloon catheter Seiyo Ikeda, MD, Hideo Yoshimoto, MD Masao Tanaka, MD, Shinji Matsumoto, MD Hideaki Itoh, MD Fukuoka, Japan To improve the diagnostic yield and safety of endoscopic retrograde balloon catheter cholangiography, two technical refinements were added: (1) intraductal retention of a balloon catheter allowing injection of a contrast medium in the supine position; and (2) slow, constant injection of the contrast medium with a heavy-duty infusion pump. Maximum filling of intrahepatic branches was attempted by both the original balloon method and the new method in seven hepatolithiasis patients. The new method was superior for visualization of the right intrahepatic ducts. Although there were no significant differences in the amount of filling of the left intrahepatic ducts, the new method provided an unobstructed view since the endoscope was out of the way. Harmful rapid increase of intraductal pressure and excessive injection of contrast medium were avoided by fluoroscopically controlled infusion. No serious complications were encountered.

Hepatolithiasis is very difficult to treat. Various types of therapeutic maneuvers including surgery have been attempted!-3 but no definitive methodology has been established. Persistence of retained stones seems to be due to incomplete visualization of the biliary tract. In order to improve the treatment of hepatolithiasis, it is mandatory that (1) the site of the intrahepatic stones be more precisely defined preoperatively, and (2) the rate of recurrence after complete removal of the stones be determined with more certainty. Our previous report demonstrated that endoscopic retrograde cholangiography (ERe) with a balloon catheter was helpful for better visualization of intrahepatic branches in selected cases where the standard method failed. 4 The purpose of this article is to describe two further technical refinements which should improve diagnostic yield: (1) removal of the endoscope while leaving the balloon catheter in the bile duct to facilitate posture change of the patient,

From the Department of Surgery I, Fukuoka University Sclwol of Medicine, and the Department of Surgery I, Kyushu University Sclwol of Medicine, Fukitoka, Japan. Reprint requests: Seiyo Ikeda, MD, Department of Surgery I, Fukuoka University School of Medicine, Nanakuma 7-45-1, Johnan-ku, Fukuoka 814-01, Japan. VOLUME 31, NO.3, 1985

and (2) slow infusion of contrast medium at a constant rate with an infusion pump. PATIENTS AND METHODS

Indications for ERC with an indwelling balloon catheter include hepatic lesions, such as stones and carcinoma, in cases of incompetent sphincter of Oddi, choledochoduodenal fistula, previous surgical sphincteroplasty, previous endoscopic sphincterotomy, and previous bilioenteric anastomosis. These indications represent conditions in which standard ERC failed to fill the intrahepatic bile ducts due to leakage of contrast medium out of the bile duct. The results of standard ERC, the original balloon method, and the new indwelling balloon catheter cholangiography method were compared in seven patients with primary intrahepatic stones (Table 1). Instruments

A side viewing duodenoscope with a 2.8-mm catheter channel (JF-1T, Olympus Optical Co., Tokyo, Japan), 3.5m long balloon catheters (Ikeda catheter JX-169, Critikon, Inc., Tampa, Florida) (Fig. 1), and a heavy-duty infusion pump (Truth A-II, similar to the Harvard pump, Nakagawa Seikodo, Tokyo) were used. The endoscope was cleared with glutaraldehyde by means of an automatic endoscope washer just before use. The catheters were sterilized with ethylene oxide gas. 181

Table 1. Summary of patients and illustrative comparison of visualization by standard ERe, balloon catheter cholangiography with endoscope in place, and indwelling balloon catheter cholangiography (new method)

Operation/procedure interval before "new method"·

Case

Age, sex

1

70, F

Cholecystectomy and CDE, 3 yr Endoscopic sphincterotomy, 2.5 yr

2

40,M

Cholecystectomy, CDE, and left lateral segmentectomy, 2 yr

3

62, F

Cholecystectomy and CDE, 21 yr Endoscopic sphincterotomy, 7 yr

Standard ERC b

Previous method b

New method

~ :." ....

".

'i) 4

54, F

Cholecystectomy, CDE, and sphincteroplasty, 2 yr Endoscopic sphincterotomy, 1 mo

5

35, F

Cholecystectomy and CDE, 3 yr Endoscopic sphincterotomy, 2.5 yr

6

38, F

Cholecystectomy and CDE, 9 yr Left lateral segmentectomy, CDE, and left hepaticojejunostomy, 8 yr

7

49,F

Cholecystojejunostomy,12

c:W{

yr

Cholecystectomy and choledochojejunostomy,2 yr

• CDE, common duct exploration. b Dotted area refers to pneumobilia. Placement of balloon catheter and cholangiography

(Fig. 2)

Preparation of the patient included intramuscular administration of butropium bromide, 4 mg, and pharyngeal anesthesia with lidocaine spray. The papilla was identified in the 182

usual manner and a balloon catheter was introduced into the bile duct. Then the posture of the patient was changed from the left decubitus position to prone. The fluoroscopy table was tilted 20 degrees with the head down, and contrast medium, 30% sodium diatrizoate (Urografin) containing antibiotics (usually thiamphenicol or dibekacin), was manually GASTROINTESTINAL ENDOSCOPY

Figure 1. A 6 French balloon catheter, 3.5 m in length, manufactured by Critikon, Inc., Tampa, Florida (Ikeda catheter JX-169). Inset, a balloon tip inflated with air.

pump -::l

-)

ff I

insertion of catheter

injection of contrast inflation medium of balloon (shaded area)

fi nal positioning of catheter

,~ II

\'

(

,, \

-prone Dr supine position

2. Schematic representation of the technique of placement of the balloon catheter and subsequent visualization of the intrahepatic bile ducts.

Figure

injected to fill the bile duct and replace intraductal air, if any, as much as possible. The balloon was inflated with air and placed at an optimal position, usually at the distal end of the common bile duct, to prevent outflow of injected contrast medium. The endoscope was slowly withdrawn over the catheter under fluoroscopic control until it was removed from the mouth, while leaving the catheter in place. The catheter was connected to the infusion pump and the contrast medium was introduced at a slow constant rate of 3 ml/min with the patient in a supine or prone position, depending on the suspected site of the intrahepatic lesion. The extent of visualization was checked by fluoroscopy or films. The injection was stopped either after satisfactory visualization or at the first sign of upper abdominal discomfort, and x-ray films were taken as needed. Before deflation of the balloon, as much injected contrast medium was retrieved as possible by using the suction mode of the pump. VOLUME 31, NO.3, 1985

RESULTS

Cholangiograms made by the original method were compared with those made when using the indwelling balloon catheter in six of the seven patients where the balloon blockade was performed at the distal end of the common bile duct. For visualization of the right intrahepatic ducts, the new method was found to be superior to the previous method (Table 1). As for the left intrahepatic ducts, there were no significant differences in the extent of filling between the two methods. However, the indwelling balloon method provided a complete and unobstructed view of that area because of the removal of the endoscope. In one patient, selective cholangiography of the left hepatic duct was carried out by the previous technique. This was also 183

performed by the new method (Table 1). All seven patients reported that the indwelling balloon method caused less discomfort. This was attributed to early removal of the endoscope, usually within 5 min from insertion. No serious complications were encountered except for one case of low grade fever presumably due to cholangitis, which subsided shortly with conservative management.

CASE REPORTS Case 1

A 72-year-old woman underwent endoscopic sphincterotomy> for removal of retained common bile duct stones in October 1978. When she returned with cholangitis 1 year later, standard ERe showed only equivocal [mdings

Figure 3. a, A film of standard endoscopic retrograde cholangiography in case 1. Air present in the right intrahepatic ducts (arrow) prevented adequate filling. b, Balloon catheter cholangiogram taken in the prone position with the endoscope in place. Injection of contrast medium with the sphincterotomy opening blocked with a balloon (small arrow), revealing multiple stones in the posteroinferior branch of the right hepatic duct (large arrow). c, Cholangiogram in the supine position with the indwelling balloon catheter, showing stones in the posterosuperior area duct (upper arrow) in addition to those in the posteroinferior branch (large arrow). d, Cholangiogram after the passage of numerous stones into the duodenum, demonstrating the disappearance of the intrahepatic stones (arrows). 184

GASTROINTESTINAL ENDOSCOPY

/

a Figure 4. a, Balloon catheter cholangiogram in case 3 obtained in t~e prone. positi~ wit~ the endoscope in place (pr~vious method), showing only sparse right intrahepatic branches. b, Cholangiogram with an indwelling ballorn:t ca~heter. Introduction of contrast medium under pressure in the supine position, providing visualization of stones in the posterolnfenor area branch of the right hepatic duct (arrow).

of intrahepatic stones (Fig. 3a). Balloon catheter cholangiography by the original method revealed multiple stones in the posteroinferior area branch of the right hepatic duct (Fig. 3b). After 2 years without symptoms, the patient underwent indwelling balloon cholangiography, which in the supine position demonstrated additional stones in the posterosuperior area duct (Fig. 3c). Eight months later, she was readmitted with cholangitis and mild jaundice. Ultrasound tomography revealed a stone in the dilated common bile duct as well as intrahepatic stones. Endoscopic bile duct decompression6 was performed, and the stone was removed with a basket catheter. Multiple small stones, 97 in number, subsequently passed through the sphincterotomy and were recovered from stools. Long-standing epigastric pain and vague abdominal symptoms completely disappeared. Repeat balloon cholangiography confirmed the disappearance of the intrahepatic stones (Fig. 3d).

Case 3

A 63-year-old woman had a cholecystectomy and common bile duct exploration in March 1961. A symptomatic stone was found in the common bile duct in December 1975 and was removed by endoscopic sphincterotomy. Six years later, however, the patient returned with pain in the right upper abdomen and back due to common bile duct stones. The stones were extracted through the sphincterotomy with a basket catheter. Subsequent balloon cholangiography by the original method showed only sparse right intrahepatic branches (Fig. 4a). The new method revealed intrahepatic stones for the first time in her clinical course (Fig. 4b). VOLUME 31, NO.3, 1985

Case 6

A 38-year-old woman underwent cholecystectomy and choledochotomy in January 1974. In June 1974, she underwent choledochotomy, resection of left lateral segment of the liver, and cholangiojejunostomy for intrahepatic stones. In August 1978, she presented with biliary tract symptoms. At this time, ERC showed stones in the intrahepatic and common bile ducts (Fig. 5a). Endoscopic sphincterotomy and basket extraction of six stones were followed by spontaneous passage of 14 additional stones (Fig. 5b, inset). Standard ERC after the procedure did not provide adequate visualization of the intrahepatic branches (Fig. 5b). Two weeks after discharge, the patient reported passing numerous stones, 180 in number, in her stools immediately after mild epigastric pain (Fig. 5c). Complete relief of the symptoms ensued. Balloon catheter cholangiography by the original method a year after the passage of stones and that by the new method 2 years later both demonstrated the absence of intrahepatic stones, the latter method giving more complete visualization (Fig. 5d).

DISCUSSION

Cases are not infrequently encountered where ERC, even when successful, provides insufficient visualization of intrahepatic bile ducts. This holds true especially for patients with hepatolithiasis who usually have an incompetent sphincter! or those with choledochoduodenal fistula? or previous sphincterotomy. ERC with the use of a balloon catheter to block the 185

/ a

c d Figure 5. a, Endoscopic retrograde cholangiogram in case 6 before sphincterotomy, demonstrating stones in the right intrahepatic ducts (arrow) and the common bile duct. b, Standard endoscopic retrograde cholangiogram after partial removal of the stones (inset) by endoscopic sphincterotomy followed by basket catheter extraction and spontaneous passage. Stones possibly remaining in the intrahepatic branches were not visualized due to insufficient filling pressure. c, Numerous stones passed in the stools shortly after discharge from the hospital. d, Cholangiogram in the supine position with the indwelling balloon catheter 3 years after the passage of the stones, providing complete visualization of the intrahepatic bile ducts and demonstrating the absence of intrahepatic stones.

escape of contrast medium was demonstrated to be extremely effective at filling the intrahepatic branches in such patients. 4 The addition of an indwelling technique and the use of an infusion pump have greatly improved the ability to fill the intrahepatic ducts (Table 1). Advantages of the removal of the endoscope 186

include (1) a decrease in the patient's discomfort during the procedure; (2) clearance of the endoscope from the fluoroscopic view, resulting in more accurate cholangiograms and less x-ray damage to the endoscope; and (3) an easier change of the patient's position. In the previous method, a large amount of conGASTROINTESTINAL ENDOSCOPY

trast medium was required to fill the right intrahepatic ducts located posteriorly since the patient's position was limited to the prone position. However, the new method has permited contrast injection in the supine position when the right lobe is the suspected site of a lesion, leading to a significant decrease in the amount of contrast medium required. Lateral views or two oblique views at slightly different angles to make three-dimensional (stereoscopic) views of the biliary tree can be obtained with ease. The new method also facilitates simultaneous cholangiography in combination with angiography or percutaneous transhepatic cholangiography to localize the lesion more precisely. The utilization of the constant infusion pump has several advantages. Harmful rapid increases of bile duct pressure and excessive contrast injection are avoided because of the slow, constant, and well controlled infusion under fluoroscopy. In addition, x-ray exposure to the examiners can be avoided since they may stand away from the fluoroscopy unit. Possible complications of balloon catheter cholangiography were fully discussed in our previous article which also included safeguards against them. 4 A few additional preventive measures have been highlighted in our improved new method. Since great care should be taken to avoid cholangitis, especially in patients with bile duct stenosis, as much injected contrast medium was removed as possible by suction with the pump immediately at the end of the procedure. Prophylactic intravenous antibiotics were also administered. Should cholangitis occur, surgical or percutaneous transhepatic drainage must be performed without delay. Injection of contrast medium should be sufficient yet minimal to avoid an excessive pressure rise which may cause bacteremia8 or hypotension. 9 For this reason, contrast medium was introduced at a slow constant rate with the aid of an infusion pump, and the extent of filling of the intrahepatic ducts was carefully controlled both under fluoroscopy and by films. Also, the area of the liver selected for visualization was kept low during the contrast injection. In cases associated with pneumobilia, possible cholangiovenous reflux of air was prevented by injecting contrast medium with the patient in the Trendelenburg position to expel air out of the biliary tree before inflation of the balloon. All patients were monitored carefully with cardiac telemetry. Although Shapiro and Cotton,lO who described the indwelling technique of a balloon catheter in the bile duct for bile collection,

VOLUME 31, NO.3, 1985

used a dilute contrast medium to inflate the balloon, air was utilized to fill the balloon in this study without any inconvenience. The success of any procedure for the treatment of hepatolithiasis requires confirmation of the absence of recurrent calculi as well as symptomatic relief for a period of more than 10 years. In postoperative followup, common duct stones migrating from the intrahepatic bile ducts are not infrequent. They are likely to be erroneously diagnosed as recurrent. If the biliary tract has been visualized to the fullest extent immediately after a therapeutic procedure, differentiation of these two situations may be possible. In this respect, the improved method of endoscopic balloon catheter cholangiography would be most suitable for a followup study, allowing detailed visualization of intrahepatic bile ducts. ACKNOWLEDGMENTS

The authors are grateful to Dr. Fumio Nakayama, Professor and Chairman of the Department of Surgery I, Kyushu University Faculty of Medicine, for encouragement and helpful criticisms, and to Dr. Mayank Kothari of Des Moines, Iowa, and Professor Robert E. Debold for valuable help in the preparation of the manuscript.

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