- Email: [email protected]
Commentary: Radiology in the Management of Bile Duct Injuries
BILIARY TRACT INJURIES REVISITED
0039-6109/94 $0.00
+ .20
COMMENTARY Interventional Radiology in the Management of Bile Duct Injuries Kenneth R. Stokes, MD
In dealing with bile duct injuries, interventional radiology clearly plays an important role in the treatment of bile leakage. In the article by vanSonnenberg et aI,B 7 of 10 patients with bile leakage were treated only with percutaneous drainage of the biloma. If necessary, biliary drainage or endoscopic stent placement can be used to divert the flow of bile. The treatment of biliary strictures is less clear. Mueller et al6 reported a 76% (19 of 25 patients) 3-year patency for dilation of iatrogenic strictures. Four additional series2, 3, 5, 10 with mean follow-up periods exceeding 15 months report similar results. Surgical series,,4, 7, 9 report postoperative stricture rates of 10% to 22%, somewhat better results than with percutaneous dilation. On the other hand, percutaneous dilation is less expensive, requires shorter hospitalization, and is less disabling for the patient. Legitimate arguments can be made to treat bile duct injuries by either surgery or interventional radiology first and, if restenosis occurs, to use the alternative method. In the end, the type of treatment depends on the age and physical condition of the patient, referral patterns, and expertise of the surgeon or radiologist. At our institution, patients with biliary strictures typically receive choledochojejunostomy. The afferent loop is placed in an antecolic position for percutaneous access. If further intervention is required, such as dilation of the anastomotic stricture, access to the biliary tree can be performed percutaneously through this loop using either a 19-9auge or 21-gauge needle and standard catheterization techniques. Injection of the needle alone often fills the biliary tree if the anastomosis is patent, and, as a result, diagnostic cholangiography can be performed as an outpatient procedure (Fig. 1). Access is simplified by placing metallic rings on the anterior aspect of the blind loop and at the biliary anastomosis at the time of surgery (Fig. 2). In the five patients who have had these
Formerly from the Section of Cardiovascular and Interventional Radiology, Department of Radiology, Deaconess Hospital, Boston, Massachusetts; currently from Radiology Associates, Baptist Medical Center, Oklahoma City, Oklahoma
SURGICAL CLINICS OF NORTH AMERICA VOLUME 74 • NUMBER 4 • AUGUST 1994
879
...
Figure 1. Choledochojejunostomy with separate left and right ductal anastomoses. Both anastomoses were dilated 1 year earlier through the blind loop. Cholangiogram shown was performed for evaluation of fever by injection of the blind loop with a 29-gauge needle. Reflux into the biliary tree revealed the anastomoses to be patent. Ductal dilation and subsequent cholangiography probably would have required separate left and right transhepatic punctures if not performed through the loop.
Figure 2. Patient had recurrent anastomotic stricture after choledochojejunostomy. An 8 French drain has been placed into the blind loop at the site of ring marker (large arrow). Anastomosis is at the level of the second ring (small arrow).
880
h s . d -
8 .
COMMENTARY: INTERVENTIONAL RADIOLOGY
881
rings placed, all required only one needle pass to enter the bowel. An angiographic guide wire can then be placed through the needle, and a selective catheter is introduced into the bowel. This is placed across the biliary stricture, usually without difficulty. Drains, balloon catheters, or stents can then be inserted. We have performed this technique 34 times in 28 patients for a variety of biliary procedures:· diagnostic cholangiography only, 12 patients; anastomotic dilation, 12 patients; biliary drainage, 18 patients; metallic or plastic stent placement up to 12 French in diameter, 9 patients; biopsy, 3 patients; and removal of calculi, 1 patient. Because there is no risk of bile leakage, a drainage catheter can be removed immediately after the procedure, shortening hospitalization. Furthermore, this procedure is much more comfortable for the patient than the transhepatic approach because the liver capsule is not crossed. To date, we have experienced only one small subcutaneous hematoma as a complication of this approach. Finally, the technique is equally advantageous in patients with anastomotic strictures after liver transplantation or tumor resection. References 1. Blumgart LH, Kelley CJ, Benjamin IS: Benign bile duct stricture following cholecystectomy: Critical factors in management. Br J Surg 71:836-843,1984 2. Citron SJ, Martin LG: Benign biliary strictures: Treatment with percutaneous cholangioplasty. Radiology 178:339-341, 1991 3. Gallacher DJ, Kadir 5, Kaufman SL, et al: Nonoperative management of benign postoperative biliary strictures. Radiology 156:625-629, 1985 4. Kalman PG, Taylor BR, Langer B: Iatrogenic bile-duct strictures. Can J Surg 25:321-324, 1982 5. Moore AV, Illescas FF, Mills SR, et al: Percutaneous dilation of benign biliary strictures. Radiology 163:625-628, 1987 6. Mueller PR, vanSonnenberg E, Ferrucci JT, et al: Biliary stricture dilatation: Multicenter review of clinical management in 73 patients. Radiology 160:17-22, 1986 7. Pellegrini CA, Thomas MJ, Way LW: Recurrent biliary stricture: Patterns of recurrence and outcome of surgical therapy. Am J Surg 147:175-180,1984 8. vanSonnenberg E, D'Agostino HB, Easter DW, et al: Complications of laparoscopic cholecystectomy: Coordinated radiologic and surgical management in 21 patients. Radiology 188:399-400, 1993 9. Way LW, Bernhoft RA, Thomas MJ: Biliary stricture. Surg Clin North Am 61:963-972, 1972 10. Williams HI, Bender CE, May GR: Benign postoperative biliary strictures: Dilation with fluoroscopic guidance. Radiology 163:629-634, 1987
Address reprint requests to Kenneth R. Stokes, MD Radiology Associates Baptist Medical Center 3330 Northwest 56th Street Suite 206 Oklahoma City, OK 73112
0039-6109/94 $0.00
+ .20
COMMENTARY Interventional Radiology in the Management of Bile Duct Injuries Kenneth R. Stokes, MD
In dealing with bile duct injuries, interventional radiology clearly plays an important role in the treatment of bile leakage. In the article by vanSonnenberg et aI,B 7 of 10 patients with bile leakage were treated only with percutaneous drainage of the biloma. If necessary, biliary drainage or endoscopic stent placement can be used to divert the flow of bile. The treatment of biliary strictures is less clear. Mueller et al6 reported a 76% (19 of 25 patients) 3-year patency for dilation of iatrogenic strictures. Four additional series2, 3, 5, 10 with mean follow-up periods exceeding 15 months report similar results. Surgical series,,4, 7, 9 report postoperative stricture rates of 10% to 22%, somewhat better results than with percutaneous dilation. On the other hand, percutaneous dilation is less expensive, requires shorter hospitalization, and is less disabling for the patient. Legitimate arguments can be made to treat bile duct injuries by either surgery or interventional radiology first and, if restenosis occurs, to use the alternative method. In the end, the type of treatment depends on the age and physical condition of the patient, referral patterns, and expertise of the surgeon or radiologist. At our institution, patients with biliary strictures typically receive choledochojejunostomy. The afferent loop is placed in an antecolic position for percutaneous access. If further intervention is required, such as dilation of the anastomotic stricture, access to the biliary tree can be performed percutaneously through this loop using either a 19-9auge or 21-gauge needle and standard catheterization techniques. Injection of the needle alone often fills the biliary tree if the anastomosis is patent, and, as a result, diagnostic cholangiography can be performed as an outpatient procedure (Fig. 1). Access is simplified by placing metallic rings on the anterior aspect of the blind loop and at the biliary anastomosis at the time of surgery (Fig. 2). In the five patients who have had these
Formerly from the Section of Cardiovascular and Interventional Radiology, Department of Radiology, Deaconess Hospital, Boston, Massachusetts; currently from Radiology Associates, Baptist Medical Center, Oklahoma City, Oklahoma
SURGICAL CLINICS OF NORTH AMERICA VOLUME 74 • NUMBER 4 • AUGUST 1994
879
...
Figure 1. Choledochojejunostomy with separate left and right ductal anastomoses. Both anastomoses were dilated 1 year earlier through the blind loop. Cholangiogram shown was performed for evaluation of fever by injection of the blind loop with a 29-gauge needle. Reflux into the biliary tree revealed the anastomoses to be patent. Ductal dilation and subsequent cholangiography probably would have required separate left and right transhepatic punctures if not performed through the loop.
Figure 2. Patient had recurrent anastomotic stricture after choledochojejunostomy. An 8 French drain has been placed into the blind loop at the site of ring marker (large arrow). Anastomosis is at the level of the second ring (small arrow).
880
h s . d -
8 .
COMMENTARY: INTERVENTIONAL RADIOLOGY
881
rings placed, all required only one needle pass to enter the bowel. An angiographic guide wire can then be placed through the needle, and a selective catheter is introduced into the bowel. This is placed across the biliary stricture, usually without difficulty. Drains, balloon catheters, or stents can then be inserted. We have performed this technique 34 times in 28 patients for a variety of biliary procedures:· diagnostic cholangiography only, 12 patients; anastomotic dilation, 12 patients; biliary drainage, 18 patients; metallic or plastic stent placement up to 12 French in diameter, 9 patients; biopsy, 3 patients; and removal of calculi, 1 patient. Because there is no risk of bile leakage, a drainage catheter can be removed immediately after the procedure, shortening hospitalization. Furthermore, this procedure is much more comfortable for the patient than the transhepatic approach because the liver capsule is not crossed. To date, we have experienced only one small subcutaneous hematoma as a complication of this approach. Finally, the technique is equally advantageous in patients with anastomotic strictures after liver transplantation or tumor resection. References 1. Blumgart LH, Kelley CJ, Benjamin IS: Benign bile duct stricture following cholecystectomy: Critical factors in management. Br J Surg 71:836-843,1984 2. Citron SJ, Martin LG: Benign biliary strictures: Treatment with percutaneous cholangioplasty. Radiology 178:339-341, 1991 3. Gallacher DJ, Kadir 5, Kaufman SL, et al: Nonoperative management of benign postoperative biliary strictures. Radiology 156:625-629, 1985 4. Kalman PG, Taylor BR, Langer B: Iatrogenic bile-duct strictures. Can J Surg 25:321-324, 1982 5. Moore AV, Illescas FF, Mills SR, et al: Percutaneous dilation of benign biliary strictures. Radiology 163:625-628, 1987 6. Mueller PR, vanSonnenberg E, Ferrucci JT, et al: Biliary stricture dilatation: Multicenter review of clinical management in 73 patients. Radiology 160:17-22, 1986 7. Pellegrini CA, Thomas MJ, Way LW: Recurrent biliary stricture: Patterns of recurrence and outcome of surgical therapy. Am J Surg 147:175-180,1984 8. vanSonnenberg E, D'Agostino HB, Easter DW, et al: Complications of laparoscopic cholecystectomy: Coordinated radiologic and surgical management in 21 patients. Radiology 188:399-400, 1993 9. Way LW, Bernhoft RA, Thomas MJ: Biliary stricture. Surg Clin North Am 61:963-972, 1972 10. Williams HI, Bender CE, May GR: Benign postoperative biliary strictures: Dilation with fluoroscopic guidance. Radiology 163:629-634, 1987
Address reprint requests to Kenneth R. Stokes, MD Radiology Associates Baptist Medical Center 3330 Northwest 56th Street Suite 206 Oklahoma City, OK 73112