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Percutaneous Management of Malignant Biliary Obstruction
Percutaneous Management of Malignant Biliary Obstruction Christopher M. Sutter, MD, and Robert K. Ryu, MD, FSIR Malignancy resulting in impaired biliary drainage includes a number of diagnoses familiar to the interventional radiologist. Adequate drainage of such a system can significantly improve patient quality of life, and can facilitate the further treatment options and care of such patients. In the setting of prior instrumentation, cholangitis can present as an urgent indication for drainage. Current initial interventional management of malignant biliary duct obstruction frequently includes endoscopic or percutaneous intervention, with local practices and preprocedural imaging guiding interventional approaches and subsequent management. This article addresses the indications for percutaneous drainage, technical considerations in performing such drainage, and specific techniques useful in attempting to achieve clinical end points in patients with malignant biliary duct obstruction. Tech Vasc Interventional Rad 18:218-226 C 2015 Elsevier Inc. All rights reserved. KEYWORDS biliary, obstruction, cancer, intervention
Introduction Malignant biliary duct obstruction (MBDO) results from the impaired passage of bile from the liver to the intestinal tract in the setting of a tumor within or adjacent to bile ducts. Diagnoses include tumors of pancreaticobiliary origin such as pancreatic cancer and cholangiocarcinoma, hepatocellular carcinoma, and metastatic disease or lymphoma involving the hepatic parenchyma or hilum. Current initial interventional management of MBDO frequently includes endoscopic or percutaneous intervention, with local practices and preprocedural imaging guiding interventional approaches and subsequent management. This article addresses the indications for percutaneous drainage, technical considerations for performing such drainage, and specific techniques useful in attempting to achieve clinical end points in patients with MBDO.
Indications When considering a percutaneous biliary intervention for a patient with known or suspected MBDO, one must first consider the clinical presentation and indication(s) Department of Radiology, University of Colorado, Aurora, CO. Address reprint requests to Robert K. Ryu, MD, FSIR, Department of Radiology, University of Colorado School of Medicine, Mail stop L954, 12401 E. 17th Ave, Room 526, Aurora, CO 80045. E-mail: [email protected]
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and the likelihood of achieving the goals of the intervention.1 The most common presentation of MBDO is jaundice, the yellowish discoloration of tissue because of retained bilirubin and bile salts in the serum (hyperbilirubinemia), which can occur as the total serum bilirubin level reaches 2-3 mg/dL. Other manifestations can include darkening of the urine (bilirubinuria) and light-colored acholic stools. Patients with this condition may also present with pruritus, which can result in significantly decreased quality of life. The pathophysiology of pruritus in these patients is poorly understood, sometimes occurring out of proportion to serum bilirubin levels. However, biliary drainage in these patients often results in considerable clinical improvement. It has been established that biliary drainage and stenting in the setting of obstruction can result in symptom relief and improved quality of life,2,3 critical factors in a patient population whose diagnosis often portends a shortened life expectancy. When a diagnosis of MBDO has been definitively established, percutaneous intervention may be performed to decrease serum bilirubin levels to allow for or facilitate medical therapy or chemotherapy, or in some cases to allow for surgery. However, in a retrospective study of patients with MBDO who were referred for percutaneous drainage to permit administration of chemotherapy, only 31% of patients attained a normal serum bilirubin level by 100 days.4 The study authors identified preprocedural total serum bilirubin levels, International
1089-2516/15/$ - see front matter & 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.tvir.2015.07.005
Percutaneous management of malignant biliary obstruction Normalized Ratio, and the degree of biliary drainage as prognostic factors in this study and emphasized the importance of patient selection when considering percutaneous biliary intervention for this indication. Cholangitis is an infrequent initial presentation of MBDO, but this presentation must always be considered when a patient has undergone a previous endoscopic or percutaneous intervention5 and when fever, right upper quadrant pain, jaundice, mental status changes, or frank sepsis accompanies obstructed bile ducts.
Technical/anatomical considerations In preparation for any biliary intervention, modern crosssectional imaging with thin-slice computed tomography (CT) and magnetic resonance (MR) imaging with MR cholangiopancreatography (MRCP) are paramount. Initial evaluation must determine whether the level of obstruction is low (below the level of the cystic duct
219 insertion) or high (above the level of the cystic duct insertion, frequently involving the biliary confluence) (Fig. 1).6 In the setting of low bile duct obstruction, complete drainage of the biliary tree can be accomplished by placement of a single catheter or stent across the obstruction. Low obstructions are frequently also amenable to endoscopic cholangiopancreatography and ER biliary drainage. Depending on local endoscopy practice, many patients with more proximal or higher obstructions undergo attempts at endoscopic management to avoid the need for percutaneous attempts and subsequent exteriorized drainage catheters. In patients with high bile duct obstruction clearly involving the confluence or more proximal ducts, or in patients for whom ER biliary drainage is not possible or unsuccessful, interventional radiology procedures for management include percutaneous cholangiography, percutaneous transhepatic biliary drainage (PTBD) and stent placement, and bile duct biopsy. A discussion of the percutaneous management of MBDO would be incomplete without a review of the Bismuth and Corlette classification of hilar carcinomas,
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Figure 1 (A) Left percutaneous cholangiogram with wire access into the duodenum demonstrates low biliary obstruction secondary to pancreatic adenocarcinoma. A small endoscopically placed plastic stent is noted in the occluded common bile duct (CBD) (arrow). (B) A single left internal or external biliary drainage catheter communicates with right ducts draining all hepatic segments. (C) Left lateral segment percutaneous cholangiogram demonstrates left hepatic duct high biliary obstruction (arrow) in a patient with cholangiocarcinoma, with drainage after placement of left PTBD (D).
C.M. Sutter and R.K. Ryu
220 useful in considerations of optimal catheter drainage and critical in considerations of surgical candidacy.7 Type I tumors involve the hepatic duct without hilar involvement. Such pathologic anatomy can theoretically be drained by a single catheter or stent across the lesion, effectively draining all proximal bile ducts. Type II tumors involve the hilum proper and require bilateral catheters, one in each of the right and left ducts for optimal drainage, or a single percutaneous external catheter that spans across the hilum, draining each hemiliver via a single catheter. Type III tumors extend to involve secondary biliary confluences on either the right or left side. Although some patients with type III tumors may be considered surgical candidates, with increased proximal extension of disease, complete percutaneous drainage becomes increasingly challenging. Some authors have described type IV tumors as those that extend to involve secondary confluences on both the right and the left sides; these tumors are typically recognized as nonoperative. In cases of such proximal extension of obstruction, although percutaneous drainage remains a technically viable option, goals and end points should continually be reassessed, as the benefit of palliation tends to decrease relative to the risks associated with intervention. Isolation occurs when obstruction extends above the central hilum, causing abnormally narrowed or absence of communication between segmental ducts. Recognizing isolation is critical when the goals of intervention might be achieved only by the drainage of
multiple segments, which in turn may require multiple catheters (Fig. 2). Preprocedural cross-sectional imaging should be rigorously interpreted to assess ductal anatomy and the specific location of biliary obstruction so that a percutaneous approach can be formulated to achieve the desired goal. The Couinaud classification of hepatic segmental anatomy is well established and useful.8 Common normal biliary ductal anatomical variants occur in up to 20% of patients; identification of these variants before the procedure can aid in interpretation of intraprocedural cholangiography and optimize the percutaneous approach. A common example is the right posterior sector duct (segments 6 and 7) draining into the left hepatic duct instead of joining the right anterior sector duct. In these cases, in the setting of a hilar obstruction, a single left PTBD (or right posterior PTBD) would effectively drain 6 hepatic segments (segments 1-4, 6, 7), whereas a right PTBD placed into the anterior sector ducts (segments 5 and 8) would drain only 2 segments.
Preprocedural Evaluation Imaging Preprocedural cross-sectional imaging with thin section CT or MRCP is necessary before percutaneous intervention is attempted in the setting of MBDO. As mentioned previously, evaluation of the ductal anatomy and level of
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Figure 2 (A) Hilar cholangiocarcinoma with complete isolation of anterior from posterior right hepatic ducts, as well as from left hepatic ducts. Prior percutaneous drainage included right anterior and posterior external biliary drainage catheters and left internal or external PTBD. (B) Cholangiogram via right anterior drain demonstrates anterior duct opacification without communication with right posterior or left ducts. Subsequent cholangiograms through (C) right posterior and (D) left drains further show absence of ductal communication, consistent with complete isolation and need for multiple drainage catheters to achieve optimal drainage.
Percutaneous management of malignant biliary obstruction
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Figure 3 (A) MRCP from a patient with hilar cholangiocarcinoma demonstrating bilateral diffuse intrahepatic biliary ductal dilatation and isolation of right and left ducts. (B) Axial and (C) coronal MR images from a patient with longstanding left portal and ductal malignant obstruction resulting in marked left hepatic lobe atrophy.
biliary obstruction allows clinicians to plan a percutaneous approach that provides optimal, targeted drainage with as few catheters and stents as possible. Preprocedural imaging also demonstrates the presence of ascites and can demonstrate portal vein thrombus (PVT) or parenchymal atrophy, information that can be used to guide targeted intervention (Fig. 3). In the setting of malignancy resulting in PVT or chronic biliary obstruction with associated segmental atrophy, drainage of such a portion of the liver would not result in improvement of liver function.9,10 Prior cross-sectional imaging and cholangiography can be used to direct drainage if there is concern for cholangitis in the setting of prior instrumentation.
Patient Preparation The patient should have a platelet count 450,000/dL and International Normalized Ratio r1.5 before percutaneous puncture is performed. As some volume of iodinated contrast is frequently administered intravascularly during biliary duct access, the patient's serum creatinine level should also be assessed. Even the most technically routine percutaneous biliary drainage procedures can be painful, and although studies suggest that conscious sedation is adequate,11 general anesthesia is recommended. General anesthesia additionally allows for immediate placement of larger catheters to optimize early drainage, without significant associated patient pain, when larger catheters are thought necessary to achieve the drainage goal or end point. The use of regional nerve blocks has also been described, but these nerve blocks have not been associated with any significant advantage.12,13 Administration of preprocedural broad-spectrum antibiotics is universally standard, even in the absence of signs or symptoms of cholangitis. Common choices include intravenous ceftriaxone, ampicillin/sulbactam, cefotetan and mezlocillin, and ampicillin and gentamicin, or for patients with allergy to penicillin, a fluoroquinolone, vancomycin, or clindamycin and an aminoglycoside.14 If cholangitis is present, postprocedural antibiotic coverage
can be based on bile cultures obtained during the procedure.
Technique Approach For most patients, percutaneous drainage is achieved on the right side because the volume of the liver is greater and more accessible. If atrophy or PVT is present on the right, or if there is concern about secondary order segmental isolation, it may be advantageous to drain the left hemiliver via the longer-length left hepatic duct. Dependent ascites is also less frequently an additional challenge in left-sided biliary drainage. After sterile preparation, right-sided drainage commences with selection of a low intercostal approach near the middle axillary line. Although initial needle puncture is classically as caudal as the 11th intercostal rib space, brief fluoroscopy of a potential access site before puncture can otherwise assist in preventing a too-cranial transpleural course. After administration of subcutaneous lidocaine for local anesthesia, an initial pass is made with a 21-gauge Chiba needle through the skin under real-time sonographic guidance toward peripheral, and frequently dilated, bile ducts. Entering a duct along its long axis can allow for a longer distance of needle puncture through the duct with an associated increased chance of ductal opacification with contrast. After puncture under ultrasound guidance, the stylet is removed, and a small syringe with attached connection tubing purged of air is attached to the needle. The needle is slowly withdrawn while contrast is gently injected until a bile duct is opacified. Bile ducts are differentiated from other intrahepatic structures by the appearance of contrast after injection. Hepatic arteries are branching structures with fast and pulsatile flow toward the hepatic periphery. Portal veins are branching nonpulsatile vessels flowing toward the periphery, and hepatic veins are nonpulsatile vessels flowing cranially. The occasionally opacified lymphatics appear as slow flow in beaded channels draining toward the hilum.
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222 Care should to be taken to avoid unnecessary introduction of air into the liver during initial contrast injection, as this can quickly obscure subsequent ultrasound access attempts. Fluoroscopically guided right-sided percutaneous punctures are directed toward the left midclavicular line, with subsequent contrast injection performed during needle withdrawal. Sonographic guidance is frequently even more useful when the need arises for the left-sided approach, as this technique can be used to identify the colon and other intervening structures. When a fluoroscopic percutaneous approach is pursued from the left, classical guidance includes an approach 3 finger breadths caudal to the xiphoid, with the needle directed 301-451 posteriorly and superiorly in attempts at biliary ductal access. When a bile duct is opacified via contrast injection through the 21-gauge needle, a percutaneous cholangiogram is performed to reevaluate preprocedural imaging results and to reassess the most appropriate approach to biliary catheter placement to achieve the desired goal. A decision must be made on whether the access is sufficiently peripheral and appropriate for catheter placement. Long hepatic tracts and central access increase the risk of hemorrhage and the possibility of inadequate drainage. If initial access is too central, the needle can be left in place and used to opacify additional ducts, which can be targeted with fluoroscopy for a second, more appropriate percutaneous needle placement. An operator must recognize the angle at which needle access is obtained, with the goal to achieve an obtuse angle between the access needle and biliary duct to facilitate further catheter or stent placement, without undue angulation or tortuosity in accessing the downstream common duct.15 After a target duct has been accessed, a 0.018-in guidewire is advanced centrally into the ducts. At this time, a small dermatotomy is created adjacent to the needle to facilitate the transitional introducer, which is placed over the guidewire after needle removal. We use a coaxial system (Accustick set, Boston Scientific, Natick, MA; or
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Neff set, Cook Medical, Bloomington, IN) with a graded dilator/introducer system including an inner metal stiffener and a tapered 4-F dilator to an outer dilator measuring 6 F. After placement, the inner stiffener and 4-F dilator are removed with the 0.018-in wire left in place as a safety wire. Through the outer 6-F dilator, a 0.035-in guidewire is advanced adjacent to the 0.018-in guidewire before 6-F catheter removal. After removal of the 6-F catheter, the 0.018-in wire is fastened in place with a hemostat to maintain safety-wire access for the duration of the case. Initial percutaneous attempts are made to cross the obstruction with a torqueable 0.035-in hydrophilic wire and a directional catheter such as a 5-F Kumpe. If the catheter can be successfully advanced into the duodenum or into the Roux limb in the setting of prior bilioenteric bypass, a stiffer 0.035-in guidewire (eg, Amplatz) can be placed. After serial dilation over this working wire, initial attempts are made to place an internal-external PTBD (Fig. 4). If the patient is under general anesthesia and it is anticipated that catheter upsizes would be necessary to achieve desired drainage, we frequently immediately upsize to a 12-F catheter. For lesions that are difficult to cross, if biliary intervention is directed at immediate decompression in the setting of infection or cholangitis or if the patient's clinical stability wavers (especially during cases for which conscious sedation alone has been employed), we place an external percutaneous biliary drain. This allows for decompression, relatively secure access, and termination of the procedure for medical resuscitation if necessary. In these cases, depending on circumstances, we frequently repeat attempted internalization to internal-external drain placement in 48-72 hours for inpatients or within 1 week for outpatients. When more challenging PTBD procedures are attempted or when targeted segmental biliary drainage is required, cone-beam CT (CBCT) has proven to be a valuable tool. After establishment of percutaneous transhepatic biliary access, injection of dilute contrast during CBCT image acquisition with subsequent multiplanar
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Figure 4 (A) Targeted percutaneous needle access to posterior right hepatic ducts in a patient with intrahepatic cholangiocarcinoma and insufficient biliary drainage after endoscopic placement of a plastic stent. (B) The access needle is exchanged over a wire for a transitional introducer, and further cholangiography is performed. The posterior right hepatic duct (arrow) is shown to drain into the left hepatic duct (arrowhead), a common biliary anomaly. (C) After wire and catheter navigation of a guidewire into the duodenum, a right-sided multiside hole biliary drainage catheter is placed, facilitating drainage of posterior right and left hepatic ducts.
Percutaneous management of malignant biliary obstruction image reformatting provides a 3-dimensional percutaneous spin cholangiogram. Such imaging can identify ductal obstruction or isolation and can provide an operator with a 3-dimensional representation when the operator assesses navigation of the obstruction to optimize stable biliary drainage (Fig. 5A and B). When compared with preprocedural conventional cross-sectional imaging including helical thin-slice CT and MR imaging, percutaneous spin cholangiography allows for confirmation of access to specific target ducts of interest, as well as communication or isolation with adjacent hepatic segments that may require additional drainage. At our institution, we have also used CBCT to facilitate the repositioning of biliary drains when necessary (Fig. 5C-F).
Stent Management of Malignant Biliary Strictures In our practice, primary stent placement after establishment of percutaneous access is rarely pursued. Patients are
223 frequently referred for biliary drainage to facilitate the initiation of chemotherapeutic regimens or for inclusion in clinical trials in which the prognosis is probably unfavorable but remains uncertain. With more aggressive surgical oncologic approaches to resection, including extended hepatectomy for rather proximal levels of MBDO, there is additional resistance among providers to place permanent metal stents. Percutaneous placement of internal metallic stents can palliate MBDO and improve the patient's quality of life and should be considered for treatment and palliation when clinically possible.16 With guidewire access across the obstruction, a sheath large enough to accommodate the stent is placed. A sheath cholangiogram is performed by injection of the sidearm of the sheath to delineate the length or extent of the obstruction, and the appropriate caliber and length of stent to cross the obstruction are determined. Stent deployment is typically initiated several centimeters distal to the final desired stent position, and after initiation of deployment, the stent can be retracted to the desired position, where the remainder of the stent is
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Figure 5 (A) Right percutaneous cholangiogram demonstrates hilar obstruction, with contrast shown to communicate with central left hepatic ducts. Despite multiple attempts, wire passage across the obstruction could not be achieved. (B) To anatomically demonstrate the hilar obstruction and facilitate wire passage, cone-beam CT cholangiography was performed. Coronal reformatted image demonstrates severe proximal CBD obstruction (arrow) with additional involvement of the left main hepatic duct (arrowhead). Contrast is shown to cross the obstruction opacifying the downstream CBD and cystic duct. (C) Axial and (D) coronal reformatted CT images show a suboptimally placed right biliary drain immediately inferior to a right rib. Despite systemic pain medication and a selective nerve block, the patient continued to have intractable pain. To reposition the drain, the tract of the existing drain was percutaneously accessed under fluoroscopic guidance via a more posteroinferior skin puncture site, such that the new drain placement would be superior to the adjacent rib. (E) Axial and (F) coronal reformatted images from intraprocedural cone-beam CT demonstrate the new access tract (arrows) satisfactorily posteroinferior to initial access (arrowheads) via the same intercostal space, now positioned superior to the next inferior adjacent rib.
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224 deployed (Fig. 6A-C). As self-expanding stents are typically deployed, with continued expansion to their nominal diameter over time, postdeployment balloon dilation is usually not employed. A postdeployment sheath cholangiogram can be performed to confirm antegrade passage of contrast material through the stent. Depending on the appearance of antegrade passage of contrast and the presence of possible hemobilia sustained during stent placement or manipulation, external biliary drain percutaneous access may be maintained. Patients in whom metal internal stents are placed who have longer life expectancies should be informed that stent occlusion over time is possible or probable and that reintervention may be necessary (Fig. 6D-F). Randomized studies have shown superior patency for metallic stents when compared with endoscopically placed polyethylene stents.17,18 Despite higher cost, the superior patency of metallic stents makes them more cost-effective than plastic stents given the lower reintervention rate. Metallic stents are prone to occlusion, however, from tumor ingrowth.
In a prospective, randomized study comparing bare metallic stents and an expanded polytetrafluoroethylene-covered stent, there was significantly increased patency, decreased stent dysfunction, and no tumor ingrowth associated with use of the covered stent.19 The mean primary patency for covered stents was 163 days (range: 15-1093 days) in a series of 70 patients with malignant distal obstruction.20 In an abstract, Orgera et al21 described the use of emergency polytetrafluoroethylene-covered stent grafts in 140 patients with malignant strictures. The stent grafts demonstrated a 78% primary patency rate at 1 year. Although the clinical efficacy of these stent grafts is plainly evident, these devices are substantially costlier than bare stents; their costeffectiveness is yet to be clearly established. Maintaining appropriate inventory level of these costly devices is also challenging for many institutions, particularly in this era of increased cost scrutiny. It has been suggested by 2 recent studies that metallic biliary stents have superior patency rates and lower complication rates (cholangitis and pancreatitis) when
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Figure 6 (A) Sheath cholangiogram demonstrates malignant obstruction of the CBD in a patient with nonresectable recurrence of pancreatic adenocarcinoma after previous Whipple surgery. (B) A self-expanding metal stent is sized and then placed across the CBD obstruction. (C) After stent deployment, cholangiography shows brisk antegrade flow across the stent with decompression of intrahepatic ducts. (D) Right percutaneous cholangiogram demonstrates occlusion of previous endoscopically placed CBD stents in a patient with advanced pancreatic cancer and cholangitis. (E) A second percutaneous access is obtained at an angle more favorable to facilitate wire and catheter navigation across the occluded CBD stents. A 5-F Kumpe catheter has been advanced into the duodenum; a large round collection of contrast represents contrast pooling in a duodenal stump, present after a previously performed palliative gastrojejunostomy. (F) Internal or external multiside hole drainage catheter positioned with side holes above and below CBD obstruction and occluded stents.
Percutaneous management of malignant biliary obstruction
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Figure 7 (A) Digital subtraction sheath cholangiogram demonstrates considerable opacification of the right portal vein (arrow). This was managed by tube upsizing and by ensuring that a side hole was not positioned across the portal vein injury. (B) Hepatic arteriography with right PTBD removed over a wire demonstrates a pseudoaneurysm along the tract of the drain (arrow). (C) Arteriography after distal and proximal coil embolization of the pseudoaneurysm shows no further filling of the pseudoaneurysm. (D) Coronal reformatted CT image showing right pleural transgression (arrow) by a PTBD in a patient requiring biliary drainage with recurrent cholangiocarcinoma after Whipple surgery. (E) After placement of a more inferior PTBD (arrow), an attempt was made to remove the transpleural drain. Contrast injection along the tract of the superior drain is shown to leak into the right pleural space (arrowhead), indicating persistent biliary pleural fistula; the drain was replaced. (F) Tractogram performed 8 weeks later shows mature tract without pleural communication; the drain was removed.
they are not placed across the sphincter of Oddi in the setting of malignant obstruction. When the level of obstruction is distal, stenting across the sphincter may be necessary. However, these preliminary studies suggest that high obstructions can be better treated by maintaining sphincter integrity.22,23
Complications Malignant biliary interventions should never be undertaken lightly: procedural mortality has been reported to be as high as 3%,24 with an associated major complication rate of 26%.25 Bacteremia and sepsis are the most common periprocedural complications. As such, prophylactic broad-spectrum antibiotics targeted toward gut organisms should be administered.14 Even with appropriate antimicrobial coverage, acute sepsis can still occur and must be managed immediately with intravascular volume support, administration of vasopressors and inotropic agents, if needed, and additional antibiotics. Patients should be transported to an intensive care setting as quickly as possible. This common, acute clinical scenario emphasizes the utility of anesthesia service support for biliary
interventions for both pain control and acute physiological deterioration. Hemorrhage from inadvertent injury to portal or hepatic venous structures frequently occurs but can usually be managed conservatively (Fig. 7A). Arterial injuries are less common but can require emergent intervention. Arterial sources of bleeding tend to be physiologically more dramatic, as opposed to accumulation of darker portal blood in a biliary drainage bag. Careful arteriography focused on the catheter track is necessary, with the catheter removed over a wire before arteriography. Any arterial abnormality in the vicinity should be considered causative and treated accordingly (Fig. 7B and C). Right-sided percutaneously placed biliary drains may be inadvertently placed adjacent to a rib and cause intractable pain because of periosteal irritation or intercostal nerve injury. Although local nerve blocks may help alleviate the pain,12 these injuries can be extremely painful to the point where the drainage catheter needs to be removed and replaced (Fig. 5C-F). Right-sided PTBD placement may also be complicated by pleural transgression, which can result in pneumothorax, hemothorax, and biliary pleural effusions, which
226 have been reported to occur in 0.5%-2% of percutaneous transhepatic cholangiography cases (Fig. 7D-F).26 Pericatheter leakage can be a seemingly innocuous nuisance but can have a dramatic negative effect on quality of life, particularly in patients receiving palliative care. Drainage catheter upsizing can help obturate patulous transhepatic tracks. Ascites leakage can be more challenging. Right-sided drains seem to have a slight predilection for this phenomenon, given the more dependent location of an intercostal approach. That said, left-sided (subcostal or subxiphoid) catheters can also leak. Oftentimes, drainage catheter upsizing will not prevent additional leakage. Paracentesis may provide short-term relief. Tunneled intraperitoneal drainage catheter placement may be necessary to help alleviate leakage. If the patient wishes to avoid any procedures, an ostomy bag can be placed over the drain site and emptied as needed. Although this is a suboptimal solution, it is a noninvasive, effective method of resolving a messy, troublesome, and uncomfortable problem.
Conclusions Successful interventional management of MBDO requires a deep understanding of anatomy, imaging expertise, technical skill, and clear understanding of the ultimate goal of treatment. Although significant complications are unsettlingly common, they can be avoided with meticulous attention to detail and careful procedural preparation. Endoscopic approaches to MBDO are generally preferred to external drainage; however, when indicated, percutaneous intervention can be lifesaving, life preserving, and aid in preserving quality of life.
References 1. House MG, Choti MA: Palliative therapy for pancreatic/biliary cancer. Surg Oncol Clin N Am 13:491-503, 2004 2. Ballinger AB, McHugh M, Catnach SM, et al: Symptom relief and quality of life after stenting for malignant bile duct obstruction. Gut 35:467-470, 1994 3. Van Laethem JL, De Broux S, Eisendrath P, et al: Clinical impact of biliary drainage and jaundice resolution in patient with obstructive metastases at the hilum. Am J Gastroenterol 98:1271-1277, 2003 4. Thornton RH, Ulrich R, Hsu M, et al: Outcomes of patients undergoing percutaneous biliary drainage to reduce bilirubin for administration of chemotherapy. J Vasc Interv Radiol 23:89-95, 2012 5. Ozden I, Tekant Y, Bilge O, et al: Endoscopic and radiologic interventions as the leading causes of severe cholangitis in a tertiary referral center. Am J Surg 189:702-706, 2005 6. Covey AM, Brown KT: Palliative percutaneous drainage in malignant biliary obstruction. Part 1: Indications and preprocedure evaluation. J Support Oncol 4:269-273, 2006 7. Bismuth H, Corlette MB: Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg Gynecol Obstet 140:170-178, 1975
C.M. Sutter and R.K. Ryu 8. Couinaud C: Le Foie; Études Anatomiques et Chirurgicales. Paris: Masson, 1957 9. Hann LE, Getrajdman GI, Brown KT, et al: Hepatic lobar atrophy: Association with ipsilateral portal vein obstruction. Am J Roentgenol 167:1017-1021, 1996 10. Covey AM, Brown KT: Percutaneous transhepatic biliary drainage. Tech Vasc Interv Radiol 11:14-20, 2008 11. Hatzidakis AA, Charonitakis E, Athanasiou A, et al: Sedations and analgesia in patients undergoing percutaneous transhepatic biliary drainage. Clin Radiol 58:121-127, 2003 12. Culp WC Jr, Cult WC: Thoracic paravertebral block for percutaneous transhepatic biliary drainage. J Vasc Interv Radiol 16:1397-1400, 2005 13. Savader SJ, Bourke DL, Venbrux AC, et al: Randomized doubleblind clinical trial of celiac plexus block for percutaneous biliary drainage. J Vasc Interv Radiol 4:539-542, 1993 14. Venkatesan AM, Kundu S, Sacks D, et al: Society of Interventional Radiology Standards of Practice Committee: Practice guidelines for adult antibiotic prophylaxis during vascular and interventional radiology procedures. Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular Interventional Radiological Society of Europe and Canadian Interventional Radiology Association [corrected]. J Vasc Interv Radiol 21:1611-1630, 2010 [erratum in J Vasc Interv Radiol 2011;22:263] 15. Saad WE: Transhepatic techniques for accessing the biliary tract. Tech Vasc Interv Radiol 11:21-42, 2008 16. Thornton RH, Covey AM: Management of malignant biliary tract obstruction. in Mauro MA, Murphy KP, Thomson KR, et al.(eds.), Philadelphia, PA: Elsevier Saunders, 981-993, 2014 17. Davids PH, Groen AK, Rauws EA, et al: Randomised trial of selfexpanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 340:1488-1492, 1992 18. Knyrim K, Wagner HJ, Pausch J, et al: A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy 25:207-212, 1993 19. Krokidis M, Fanelli F, Orgera G, et al: Percutaneous treatment of malignant jaundice due to extrahepatic cholangiocarcinoma: Covered Viabil stent versus uncovered Wallstents. Cardiovasc Intervent Radiol 33:97-106, 2010 20. Bakhru M, Ho HC, Gohil V, et al: Fully-covered, self-expandable metal stents (CSEMS) in malignant distal biliary strictures: Mid-term evaluation. J Gastroenterol Hepatol 26:1022-1027, 2011 21. Orgera G, Ganelli F, Hatzidakis A, et al: e-PTFE covered metallic stents for palliation of malignant biliary strictures: Clinical results in 140 patients. Cardiovasc Intervent Radiol 30:141, 2007 (suppl 1) 22. Huang X, Shen L, Jin Y, et al: Comparison of uncovered stent placement across versus above the main duodenal papilla for malignant biliary obstruction. J Vasc Interv Radiol 26:432-437, 2015 23. Jo JH, Park BH: Suprapapillary versus transpapillary stent placement for malignant biliary obstruction: Which is better? J Vasc Interv Radiol 26:573-582, 2015 24. Yee AC, Ho CS: Complications of percutaneous biliary drainage: Benign vs malignant diseases. Am J Roentgenol 148:1207-1209, 1987 25. Li M, Bai M, Qi X, et al: Percutaneous transhepatic biliary metal stent for malignant hilar obstruction: Results and predictive factors for efficacy in 159 patients from a single center. Cardiovasc Intervent Radiol 38:709-721, 2004 26. Winick AB, Waybill PN, Venbrux AC: Complications of percutaneous transhepatic biliary interventions. Tech Vasc Interv Radiol 4:200-206, 2001
Introduction Malignant biliary duct obstruction (MBDO) results from the impaired passage of bile from the liver to the intestinal tract in the setting of a tumor within or adjacent to bile ducts. Diagnoses include tumors of pancreaticobiliary origin such as pancreatic cancer and cholangiocarcinoma, hepatocellular carcinoma, and metastatic disease or lymphoma involving the hepatic parenchyma or hilum. Current initial interventional management of MBDO frequently includes endoscopic or percutaneous intervention, with local practices and preprocedural imaging guiding interventional approaches and subsequent management. This article addresses the indications for percutaneous drainage, technical considerations for performing such drainage, and specific techniques useful in attempting to achieve clinical end points in patients with MBDO.
Indications When considering a percutaneous biliary intervention for a patient with known or suspected MBDO, one must first consider the clinical presentation and indication(s) Department of Radiology, University of Colorado, Aurora, CO. Address reprint requests to Robert K. Ryu, MD, FSIR, Department of Radiology, University of Colorado School of Medicine, Mail stop L954, 12401 E. 17th Ave, Room 526, Aurora, CO 80045. E-mail: [email protected]
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and the likelihood of achieving the goals of the intervention.1 The most common presentation of MBDO is jaundice, the yellowish discoloration of tissue because of retained bilirubin and bile salts in the serum (hyperbilirubinemia), which can occur as the total serum bilirubin level reaches 2-3 mg/dL. Other manifestations can include darkening of the urine (bilirubinuria) and light-colored acholic stools. Patients with this condition may also present with pruritus, which can result in significantly decreased quality of life. The pathophysiology of pruritus in these patients is poorly understood, sometimes occurring out of proportion to serum bilirubin levels. However, biliary drainage in these patients often results in considerable clinical improvement. It has been established that biliary drainage and stenting in the setting of obstruction can result in symptom relief and improved quality of life,2,3 critical factors in a patient population whose diagnosis often portends a shortened life expectancy. When a diagnosis of MBDO has been definitively established, percutaneous intervention may be performed to decrease serum bilirubin levels to allow for or facilitate medical therapy or chemotherapy, or in some cases to allow for surgery. However, in a retrospective study of patients with MBDO who were referred for percutaneous drainage to permit administration of chemotherapy, only 31% of patients attained a normal serum bilirubin level by 100 days.4 The study authors identified preprocedural total serum bilirubin levels, International
1089-2516/15/$ - see front matter & 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.tvir.2015.07.005
Percutaneous management of malignant biliary obstruction Normalized Ratio, and the degree of biliary drainage as prognostic factors in this study and emphasized the importance of patient selection when considering percutaneous biliary intervention for this indication. Cholangitis is an infrequent initial presentation of MBDO, but this presentation must always be considered when a patient has undergone a previous endoscopic or percutaneous intervention5 and when fever, right upper quadrant pain, jaundice, mental status changes, or frank sepsis accompanies obstructed bile ducts.
Technical/anatomical considerations In preparation for any biliary intervention, modern crosssectional imaging with thin-slice computed tomography (CT) and magnetic resonance (MR) imaging with MR cholangiopancreatography (MRCP) are paramount. Initial evaluation must determine whether the level of obstruction is low (below the level of the cystic duct
219 insertion) or high (above the level of the cystic duct insertion, frequently involving the biliary confluence) (Fig. 1).6 In the setting of low bile duct obstruction, complete drainage of the biliary tree can be accomplished by placement of a single catheter or stent across the obstruction. Low obstructions are frequently also amenable to endoscopic cholangiopancreatography and ER biliary drainage. Depending on local endoscopy practice, many patients with more proximal or higher obstructions undergo attempts at endoscopic management to avoid the need for percutaneous attempts and subsequent exteriorized drainage catheters. In patients with high bile duct obstruction clearly involving the confluence or more proximal ducts, or in patients for whom ER biliary drainage is not possible or unsuccessful, interventional radiology procedures for management include percutaneous cholangiography, percutaneous transhepatic biliary drainage (PTBD) and stent placement, and bile duct biopsy. A discussion of the percutaneous management of MBDO would be incomplete without a review of the Bismuth and Corlette classification of hilar carcinomas,
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Figure 1 (A) Left percutaneous cholangiogram with wire access into the duodenum demonstrates low biliary obstruction secondary to pancreatic adenocarcinoma. A small endoscopically placed plastic stent is noted in the occluded common bile duct (CBD) (arrow). (B) A single left internal or external biliary drainage catheter communicates with right ducts draining all hepatic segments. (C) Left lateral segment percutaneous cholangiogram demonstrates left hepatic duct high biliary obstruction (arrow) in a patient with cholangiocarcinoma, with drainage after placement of left PTBD (D).
C.M. Sutter and R.K. Ryu
220 useful in considerations of optimal catheter drainage and critical in considerations of surgical candidacy.7 Type I tumors involve the hepatic duct without hilar involvement. Such pathologic anatomy can theoretically be drained by a single catheter or stent across the lesion, effectively draining all proximal bile ducts. Type II tumors involve the hilum proper and require bilateral catheters, one in each of the right and left ducts for optimal drainage, or a single percutaneous external catheter that spans across the hilum, draining each hemiliver via a single catheter. Type III tumors extend to involve secondary biliary confluences on either the right or left side. Although some patients with type III tumors may be considered surgical candidates, with increased proximal extension of disease, complete percutaneous drainage becomes increasingly challenging. Some authors have described type IV tumors as those that extend to involve secondary confluences on both the right and the left sides; these tumors are typically recognized as nonoperative. In cases of such proximal extension of obstruction, although percutaneous drainage remains a technically viable option, goals and end points should continually be reassessed, as the benefit of palliation tends to decrease relative to the risks associated with intervention. Isolation occurs when obstruction extends above the central hilum, causing abnormally narrowed or absence of communication between segmental ducts. Recognizing isolation is critical when the goals of intervention might be achieved only by the drainage of
multiple segments, which in turn may require multiple catheters (Fig. 2). Preprocedural cross-sectional imaging should be rigorously interpreted to assess ductal anatomy and the specific location of biliary obstruction so that a percutaneous approach can be formulated to achieve the desired goal. The Couinaud classification of hepatic segmental anatomy is well established and useful.8 Common normal biliary ductal anatomical variants occur in up to 20% of patients; identification of these variants before the procedure can aid in interpretation of intraprocedural cholangiography and optimize the percutaneous approach. A common example is the right posterior sector duct (segments 6 and 7) draining into the left hepatic duct instead of joining the right anterior sector duct. In these cases, in the setting of a hilar obstruction, a single left PTBD (or right posterior PTBD) would effectively drain 6 hepatic segments (segments 1-4, 6, 7), whereas a right PTBD placed into the anterior sector ducts (segments 5 and 8) would drain only 2 segments.
Preprocedural Evaluation Imaging Preprocedural cross-sectional imaging with thin section CT or MRCP is necessary before percutaneous intervention is attempted in the setting of MBDO. As mentioned previously, evaluation of the ductal anatomy and level of
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Figure 2 (A) Hilar cholangiocarcinoma with complete isolation of anterior from posterior right hepatic ducts, as well as from left hepatic ducts. Prior percutaneous drainage included right anterior and posterior external biliary drainage catheters and left internal or external PTBD. (B) Cholangiogram via right anterior drain demonstrates anterior duct opacification without communication with right posterior or left ducts. Subsequent cholangiograms through (C) right posterior and (D) left drains further show absence of ductal communication, consistent with complete isolation and need for multiple drainage catheters to achieve optimal drainage.
Percutaneous management of malignant biliary obstruction
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Figure 3 (A) MRCP from a patient with hilar cholangiocarcinoma demonstrating bilateral diffuse intrahepatic biliary ductal dilatation and isolation of right and left ducts. (B) Axial and (C) coronal MR images from a patient with longstanding left portal and ductal malignant obstruction resulting in marked left hepatic lobe atrophy.
biliary obstruction allows clinicians to plan a percutaneous approach that provides optimal, targeted drainage with as few catheters and stents as possible. Preprocedural imaging also demonstrates the presence of ascites and can demonstrate portal vein thrombus (PVT) or parenchymal atrophy, information that can be used to guide targeted intervention (Fig. 3). In the setting of malignancy resulting in PVT or chronic biliary obstruction with associated segmental atrophy, drainage of such a portion of the liver would not result in improvement of liver function.9,10 Prior cross-sectional imaging and cholangiography can be used to direct drainage if there is concern for cholangitis in the setting of prior instrumentation.
Patient Preparation The patient should have a platelet count 450,000/dL and International Normalized Ratio r1.5 before percutaneous puncture is performed. As some volume of iodinated contrast is frequently administered intravascularly during biliary duct access, the patient's serum creatinine level should also be assessed. Even the most technically routine percutaneous biliary drainage procedures can be painful, and although studies suggest that conscious sedation is adequate,11 general anesthesia is recommended. General anesthesia additionally allows for immediate placement of larger catheters to optimize early drainage, without significant associated patient pain, when larger catheters are thought necessary to achieve the drainage goal or end point. The use of regional nerve blocks has also been described, but these nerve blocks have not been associated with any significant advantage.12,13 Administration of preprocedural broad-spectrum antibiotics is universally standard, even in the absence of signs or symptoms of cholangitis. Common choices include intravenous ceftriaxone, ampicillin/sulbactam, cefotetan and mezlocillin, and ampicillin and gentamicin, or for patients with allergy to penicillin, a fluoroquinolone, vancomycin, or clindamycin and an aminoglycoside.14 If cholangitis is present, postprocedural antibiotic coverage
can be based on bile cultures obtained during the procedure.
Technique Approach For most patients, percutaneous drainage is achieved on the right side because the volume of the liver is greater and more accessible. If atrophy or PVT is present on the right, or if there is concern about secondary order segmental isolation, it may be advantageous to drain the left hemiliver via the longer-length left hepatic duct. Dependent ascites is also less frequently an additional challenge in left-sided biliary drainage. After sterile preparation, right-sided drainage commences with selection of a low intercostal approach near the middle axillary line. Although initial needle puncture is classically as caudal as the 11th intercostal rib space, brief fluoroscopy of a potential access site before puncture can otherwise assist in preventing a too-cranial transpleural course. After administration of subcutaneous lidocaine for local anesthesia, an initial pass is made with a 21-gauge Chiba needle through the skin under real-time sonographic guidance toward peripheral, and frequently dilated, bile ducts. Entering a duct along its long axis can allow for a longer distance of needle puncture through the duct with an associated increased chance of ductal opacification with contrast. After puncture under ultrasound guidance, the stylet is removed, and a small syringe with attached connection tubing purged of air is attached to the needle. The needle is slowly withdrawn while contrast is gently injected until a bile duct is opacified. Bile ducts are differentiated from other intrahepatic structures by the appearance of contrast after injection. Hepatic arteries are branching structures with fast and pulsatile flow toward the hepatic periphery. Portal veins are branching nonpulsatile vessels flowing toward the periphery, and hepatic veins are nonpulsatile vessels flowing cranially. The occasionally opacified lymphatics appear as slow flow in beaded channels draining toward the hilum.
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222 Care should to be taken to avoid unnecessary introduction of air into the liver during initial contrast injection, as this can quickly obscure subsequent ultrasound access attempts. Fluoroscopically guided right-sided percutaneous punctures are directed toward the left midclavicular line, with subsequent contrast injection performed during needle withdrawal. Sonographic guidance is frequently even more useful when the need arises for the left-sided approach, as this technique can be used to identify the colon and other intervening structures. When a fluoroscopic percutaneous approach is pursued from the left, classical guidance includes an approach 3 finger breadths caudal to the xiphoid, with the needle directed 301-451 posteriorly and superiorly in attempts at biliary ductal access. When a bile duct is opacified via contrast injection through the 21-gauge needle, a percutaneous cholangiogram is performed to reevaluate preprocedural imaging results and to reassess the most appropriate approach to biliary catheter placement to achieve the desired goal. A decision must be made on whether the access is sufficiently peripheral and appropriate for catheter placement. Long hepatic tracts and central access increase the risk of hemorrhage and the possibility of inadequate drainage. If initial access is too central, the needle can be left in place and used to opacify additional ducts, which can be targeted with fluoroscopy for a second, more appropriate percutaneous needle placement. An operator must recognize the angle at which needle access is obtained, with the goal to achieve an obtuse angle between the access needle and biliary duct to facilitate further catheter or stent placement, without undue angulation or tortuosity in accessing the downstream common duct.15 After a target duct has been accessed, a 0.018-in guidewire is advanced centrally into the ducts. At this time, a small dermatotomy is created adjacent to the needle to facilitate the transitional introducer, which is placed over the guidewire after needle removal. We use a coaxial system (Accustick set, Boston Scientific, Natick, MA; or
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Neff set, Cook Medical, Bloomington, IN) with a graded dilator/introducer system including an inner metal stiffener and a tapered 4-F dilator to an outer dilator measuring 6 F. After placement, the inner stiffener and 4-F dilator are removed with the 0.018-in wire left in place as a safety wire. Through the outer 6-F dilator, a 0.035-in guidewire is advanced adjacent to the 0.018-in guidewire before 6-F catheter removal. After removal of the 6-F catheter, the 0.018-in wire is fastened in place with a hemostat to maintain safety-wire access for the duration of the case. Initial percutaneous attempts are made to cross the obstruction with a torqueable 0.035-in hydrophilic wire and a directional catheter such as a 5-F Kumpe. If the catheter can be successfully advanced into the duodenum or into the Roux limb in the setting of prior bilioenteric bypass, a stiffer 0.035-in guidewire (eg, Amplatz) can be placed. After serial dilation over this working wire, initial attempts are made to place an internal-external PTBD (Fig. 4). If the patient is under general anesthesia and it is anticipated that catheter upsizes would be necessary to achieve desired drainage, we frequently immediately upsize to a 12-F catheter. For lesions that are difficult to cross, if biliary intervention is directed at immediate decompression in the setting of infection or cholangitis or if the patient's clinical stability wavers (especially during cases for which conscious sedation alone has been employed), we place an external percutaneous biliary drain. This allows for decompression, relatively secure access, and termination of the procedure for medical resuscitation if necessary. In these cases, depending on circumstances, we frequently repeat attempted internalization to internal-external drain placement in 48-72 hours for inpatients or within 1 week for outpatients. When more challenging PTBD procedures are attempted or when targeted segmental biliary drainage is required, cone-beam CT (CBCT) has proven to be a valuable tool. After establishment of percutaneous transhepatic biliary access, injection of dilute contrast during CBCT image acquisition with subsequent multiplanar
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Figure 4 (A) Targeted percutaneous needle access to posterior right hepatic ducts in a patient with intrahepatic cholangiocarcinoma and insufficient biliary drainage after endoscopic placement of a plastic stent. (B) The access needle is exchanged over a wire for a transitional introducer, and further cholangiography is performed. The posterior right hepatic duct (arrow) is shown to drain into the left hepatic duct (arrowhead), a common biliary anomaly. (C) After wire and catheter navigation of a guidewire into the duodenum, a right-sided multiside hole biliary drainage catheter is placed, facilitating drainage of posterior right and left hepatic ducts.
Percutaneous management of malignant biliary obstruction image reformatting provides a 3-dimensional percutaneous spin cholangiogram. Such imaging can identify ductal obstruction or isolation and can provide an operator with a 3-dimensional representation when the operator assesses navigation of the obstruction to optimize stable biliary drainage (Fig. 5A and B). When compared with preprocedural conventional cross-sectional imaging including helical thin-slice CT and MR imaging, percutaneous spin cholangiography allows for confirmation of access to specific target ducts of interest, as well as communication or isolation with adjacent hepatic segments that may require additional drainage. At our institution, we have also used CBCT to facilitate the repositioning of biliary drains when necessary (Fig. 5C-F).
Stent Management of Malignant Biliary Strictures In our practice, primary stent placement after establishment of percutaneous access is rarely pursued. Patients are
223 frequently referred for biliary drainage to facilitate the initiation of chemotherapeutic regimens or for inclusion in clinical trials in which the prognosis is probably unfavorable but remains uncertain. With more aggressive surgical oncologic approaches to resection, including extended hepatectomy for rather proximal levels of MBDO, there is additional resistance among providers to place permanent metal stents. Percutaneous placement of internal metallic stents can palliate MBDO and improve the patient's quality of life and should be considered for treatment and palliation when clinically possible.16 With guidewire access across the obstruction, a sheath large enough to accommodate the stent is placed. A sheath cholangiogram is performed by injection of the sidearm of the sheath to delineate the length or extent of the obstruction, and the appropriate caliber and length of stent to cross the obstruction are determined. Stent deployment is typically initiated several centimeters distal to the final desired stent position, and after initiation of deployment, the stent can be retracted to the desired position, where the remainder of the stent is
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Figure 5 (A) Right percutaneous cholangiogram demonstrates hilar obstruction, with contrast shown to communicate with central left hepatic ducts. Despite multiple attempts, wire passage across the obstruction could not be achieved. (B) To anatomically demonstrate the hilar obstruction and facilitate wire passage, cone-beam CT cholangiography was performed. Coronal reformatted image demonstrates severe proximal CBD obstruction (arrow) with additional involvement of the left main hepatic duct (arrowhead). Contrast is shown to cross the obstruction opacifying the downstream CBD and cystic duct. (C) Axial and (D) coronal reformatted CT images show a suboptimally placed right biliary drain immediately inferior to a right rib. Despite systemic pain medication and a selective nerve block, the patient continued to have intractable pain. To reposition the drain, the tract of the existing drain was percutaneously accessed under fluoroscopic guidance via a more posteroinferior skin puncture site, such that the new drain placement would be superior to the adjacent rib. (E) Axial and (F) coronal reformatted images from intraprocedural cone-beam CT demonstrate the new access tract (arrows) satisfactorily posteroinferior to initial access (arrowheads) via the same intercostal space, now positioned superior to the next inferior adjacent rib.
C.M. Sutter and R.K. Ryu
224 deployed (Fig. 6A-C). As self-expanding stents are typically deployed, with continued expansion to their nominal diameter over time, postdeployment balloon dilation is usually not employed. A postdeployment sheath cholangiogram can be performed to confirm antegrade passage of contrast material through the stent. Depending on the appearance of antegrade passage of contrast and the presence of possible hemobilia sustained during stent placement or manipulation, external biliary drain percutaneous access may be maintained. Patients in whom metal internal stents are placed who have longer life expectancies should be informed that stent occlusion over time is possible or probable and that reintervention may be necessary (Fig. 6D-F). Randomized studies have shown superior patency for metallic stents when compared with endoscopically placed polyethylene stents.17,18 Despite higher cost, the superior patency of metallic stents makes them more cost-effective than plastic stents given the lower reintervention rate. Metallic stents are prone to occlusion, however, from tumor ingrowth.
In a prospective, randomized study comparing bare metallic stents and an expanded polytetrafluoroethylene-covered stent, there was significantly increased patency, decreased stent dysfunction, and no tumor ingrowth associated with use of the covered stent.19 The mean primary patency for covered stents was 163 days (range: 15-1093 days) in a series of 70 patients with malignant distal obstruction.20 In an abstract, Orgera et al21 described the use of emergency polytetrafluoroethylene-covered stent grafts in 140 patients with malignant strictures. The stent grafts demonstrated a 78% primary patency rate at 1 year. Although the clinical efficacy of these stent grafts is plainly evident, these devices are substantially costlier than bare stents; their costeffectiveness is yet to be clearly established. Maintaining appropriate inventory level of these costly devices is also challenging for many institutions, particularly in this era of increased cost scrutiny. It has been suggested by 2 recent studies that metallic biliary stents have superior patency rates and lower complication rates (cholangitis and pancreatitis) when
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Figure 6 (A) Sheath cholangiogram demonstrates malignant obstruction of the CBD in a patient with nonresectable recurrence of pancreatic adenocarcinoma after previous Whipple surgery. (B) A self-expanding metal stent is sized and then placed across the CBD obstruction. (C) After stent deployment, cholangiography shows brisk antegrade flow across the stent with decompression of intrahepatic ducts. (D) Right percutaneous cholangiogram demonstrates occlusion of previous endoscopically placed CBD stents in a patient with advanced pancreatic cancer and cholangitis. (E) A second percutaneous access is obtained at an angle more favorable to facilitate wire and catheter navigation across the occluded CBD stents. A 5-F Kumpe catheter has been advanced into the duodenum; a large round collection of contrast represents contrast pooling in a duodenal stump, present after a previously performed palliative gastrojejunostomy. (F) Internal or external multiside hole drainage catheter positioned with side holes above and below CBD obstruction and occluded stents.
Percutaneous management of malignant biliary obstruction
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Figure 7 (A) Digital subtraction sheath cholangiogram demonstrates considerable opacification of the right portal vein (arrow). This was managed by tube upsizing and by ensuring that a side hole was not positioned across the portal vein injury. (B) Hepatic arteriography with right PTBD removed over a wire demonstrates a pseudoaneurysm along the tract of the drain (arrow). (C) Arteriography after distal and proximal coil embolization of the pseudoaneurysm shows no further filling of the pseudoaneurysm. (D) Coronal reformatted CT image showing right pleural transgression (arrow) by a PTBD in a patient requiring biliary drainage with recurrent cholangiocarcinoma after Whipple surgery. (E) After placement of a more inferior PTBD (arrow), an attempt was made to remove the transpleural drain. Contrast injection along the tract of the superior drain is shown to leak into the right pleural space (arrowhead), indicating persistent biliary pleural fistula; the drain was replaced. (F) Tractogram performed 8 weeks later shows mature tract without pleural communication; the drain was removed.
they are not placed across the sphincter of Oddi in the setting of malignant obstruction. When the level of obstruction is distal, stenting across the sphincter may be necessary. However, these preliminary studies suggest that high obstructions can be better treated by maintaining sphincter integrity.22,23
Complications Malignant biliary interventions should never be undertaken lightly: procedural mortality has been reported to be as high as 3%,24 with an associated major complication rate of 26%.25 Bacteremia and sepsis are the most common periprocedural complications. As such, prophylactic broad-spectrum antibiotics targeted toward gut organisms should be administered.14 Even with appropriate antimicrobial coverage, acute sepsis can still occur and must be managed immediately with intravascular volume support, administration of vasopressors and inotropic agents, if needed, and additional antibiotics. Patients should be transported to an intensive care setting as quickly as possible. This common, acute clinical scenario emphasizes the utility of anesthesia service support for biliary
interventions for both pain control and acute physiological deterioration. Hemorrhage from inadvertent injury to portal or hepatic venous structures frequently occurs but can usually be managed conservatively (Fig. 7A). Arterial injuries are less common but can require emergent intervention. Arterial sources of bleeding tend to be physiologically more dramatic, as opposed to accumulation of darker portal blood in a biliary drainage bag. Careful arteriography focused on the catheter track is necessary, with the catheter removed over a wire before arteriography. Any arterial abnormality in the vicinity should be considered causative and treated accordingly (Fig. 7B and C). Right-sided percutaneously placed biliary drains may be inadvertently placed adjacent to a rib and cause intractable pain because of periosteal irritation or intercostal nerve injury. Although local nerve blocks may help alleviate the pain,12 these injuries can be extremely painful to the point where the drainage catheter needs to be removed and replaced (Fig. 5C-F). Right-sided PTBD placement may also be complicated by pleural transgression, which can result in pneumothorax, hemothorax, and biliary pleural effusions, which
226 have been reported to occur in 0.5%-2% of percutaneous transhepatic cholangiography cases (Fig. 7D-F).26 Pericatheter leakage can be a seemingly innocuous nuisance but can have a dramatic negative effect on quality of life, particularly in patients receiving palliative care. Drainage catheter upsizing can help obturate patulous transhepatic tracks. Ascites leakage can be more challenging. Right-sided drains seem to have a slight predilection for this phenomenon, given the more dependent location of an intercostal approach. That said, left-sided (subcostal or subxiphoid) catheters can also leak. Oftentimes, drainage catheter upsizing will not prevent additional leakage. Paracentesis may provide short-term relief. Tunneled intraperitoneal drainage catheter placement may be necessary to help alleviate leakage. If the patient wishes to avoid any procedures, an ostomy bag can be placed over the drain site and emptied as needed. Although this is a suboptimal solution, it is a noninvasive, effective method of resolving a messy, troublesome, and uncomfortable problem.
Conclusions Successful interventional management of MBDO requires a deep understanding of anatomy, imaging expertise, technical skill, and clear understanding of the ultimate goal of treatment. Although significant complications are unsettlingly common, they can be avoided with meticulous attention to detail and careful procedural preparation. Endoscopic approaches to MBDO are generally preferred to external drainage; however, when indicated, percutaneous intervention can be lifesaving, life preserving, and aid in preserving quality of life.
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C.M. Sutter and R.K. Ryu 8. Couinaud C: Le Foie; Études Anatomiques et Chirurgicales. Paris: Masson, 1957 9. Hann LE, Getrajdman GI, Brown KT, et al: Hepatic lobar atrophy: Association with ipsilateral portal vein obstruction. Am J Roentgenol 167:1017-1021, 1996 10. Covey AM, Brown KT: Percutaneous transhepatic biliary drainage. Tech Vasc Interv Radiol 11:14-20, 2008 11. Hatzidakis AA, Charonitakis E, Athanasiou A, et al: Sedations and analgesia in patients undergoing percutaneous transhepatic biliary drainage. Clin Radiol 58:121-127, 2003 12. Culp WC Jr, Cult WC: Thoracic paravertebral block for percutaneous transhepatic biliary drainage. J Vasc Interv Radiol 16:1397-1400, 2005 13. Savader SJ, Bourke DL, Venbrux AC, et al: Randomized doubleblind clinical trial of celiac plexus block for percutaneous biliary drainage. J Vasc Interv Radiol 4:539-542, 1993 14. Venkatesan AM, Kundu S, Sacks D, et al: Society of Interventional Radiology Standards of Practice Committee: Practice guidelines for adult antibiotic prophylaxis during vascular and interventional radiology procedures. Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular Interventional Radiological Society of Europe and Canadian Interventional Radiology Association [corrected]. J Vasc Interv Radiol 21:1611-1630, 2010 [erratum in J Vasc Interv Radiol 2011;22:263] 15. Saad WE: Transhepatic techniques for accessing the biliary tract. Tech Vasc Interv Radiol 11:21-42, 2008 16. Thornton RH, Covey AM: Management of malignant biliary tract obstruction. in Mauro MA, Murphy KP, Thomson KR, et al.(eds.), Philadelphia, PA: Elsevier Saunders, 981-993, 2014 17. Davids PH, Groen AK, Rauws EA, et al: Randomised trial of selfexpanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 340:1488-1492, 1992 18. Knyrim K, Wagner HJ, Pausch J, et al: A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy 25:207-212, 1993 19. Krokidis M, Fanelli F, Orgera G, et al: Percutaneous treatment of malignant jaundice due to extrahepatic cholangiocarcinoma: Covered Viabil stent versus uncovered Wallstents. Cardiovasc Intervent Radiol 33:97-106, 2010 20. Bakhru M, Ho HC, Gohil V, et al: Fully-covered, self-expandable metal stents (CSEMS) in malignant distal biliary strictures: Mid-term evaluation. J Gastroenterol Hepatol 26:1022-1027, 2011 21. Orgera G, Ganelli F, Hatzidakis A, et al: e-PTFE covered metallic stents for palliation of malignant biliary strictures: Clinical results in 140 patients. Cardiovasc Intervent Radiol 30:141, 2007 (suppl 1) 22. Huang X, Shen L, Jin Y, et al: Comparison of uncovered stent placement across versus above the main duodenal papilla for malignant biliary obstruction. J Vasc Interv Radiol 26:432-437, 2015 23. Jo JH, Park BH: Suprapapillary versus transpapillary stent placement for malignant biliary obstruction: Which is better? J Vasc Interv Radiol 26:573-582, 2015 24. Yee AC, Ho CS: Complications of percutaneous biliary drainage: Benign vs malignant diseases. Am J Roentgenol 148:1207-1209, 1987 25. Li M, Bai M, Qi X, et al: Percutaneous transhepatic biliary metal stent for malignant hilar obstruction: Results and predictive factors for efficacy in 159 patients from a single center. Cardiovasc Intervent Radiol 38:709-721, 2004 26. Winick AB, Waybill PN, Venbrux AC: Complications of percutaneous transhepatic biliary interventions. Tech Vasc Interv Radiol 4:200-206, 2001