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Percutaneous Transhepatic Biliary Drainage
Percutaneous Transhepatic Biliary Drainage Anne M. Covey, MD, and Karen T. Brown, MD Over the past three decades, endoscopic and percutaneous biliary drainage have become readily available in most hospital settings and these minimally invasive techniques have revolutionized the treatment of patients with biliary obstruction. In the past, treatment of biliary obstruction had required surgery under general anesthesia and an extended hospital stay. Currently, the same patient can most often be treated either endoscopically as an outpatient or during a short hospital stay after percutaneous drainage under moderate sedation. This article reviews the indications and technique of percutaneous transhepatic cholangiography and biliary drainage. Tech Vasc Interventional Rad 11:14-20 © 2008 Elsevier Inc. All rights reserved. KEYWORDS biliary drainage, transhepatic cholangiography, jaundice, decompressed ducts, biliary complications
O
ver the past three decades, endoscopic and percutaneous biliary drainage have become readily available in most hospital settings and these minimally invasive techniques have revolutionized the treatment of patients with biliary obstruction. In the past, treatment of biliary obstruction had required surgery under general anesthesia and an extended hospital stay.1 Currently, the same patient can most often be treated either endoscopically as an outpatient or during a short hospital stay after percutaneous drainage under moderate sedation. The purpose of this article is to review the indications and technique of percutaneous transhepatic cholangiography and biliary drainage.
Indication for Biliary Drainage Before committing a patient to any invasive procedure, it is important to have a clearly defined goal.2 Biliary intervention, like any invasive procedure, may have complications and external catheters require maintenance and impact lifestyle. Signs and symptoms of biliary obstruction vary depending on the disease process, history of prior intervention, and comorbidities. Clinical jaundice is common with a serum bilirubin over 3 mg/dL.3 Pruritus is a common symptom in patients with biliary obstruction. Pruritus is often out of proportion to the serum bilirubin level and bile acid profile4 and the pathogenesis is poorly understood. Pruritus can have a pronounced deleterious effect on quality of life and is usually relieved by drainage of even a single liver segment.5-7
Weill Medical College of Cornell University, Memorial Hospital, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. Address reprint requests to: Anne M. Covey, MD, Memorial Sloan-Kettering Cancer, Department of Radiology, 1275 York Avenue, New York, NY 10021. E-mail: [email protected].
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1089-2516/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.tvir.2008.05.003
Patients with obstructive jaundice may also complain of alteration in taste of food or frank anorexia that is relieved with re-establishment of the normal enterohepatic circulation of bile.8 Cholangitis almost always occurs in the setting of a previously instrumented or manipulated biliary tree resulting from direct or enteric contamination of an obstructed system.9 The inciting event is most commonly iatrogenic— endoscopic retrograde chlangiopancreatography (ERCP), sphincterotomy, or surgery— but occasionally cholangitis occurs because of colonized gallstones or an enteric fistula. Cholestasis may affect the function of Kupfer cells resulting in decreased effectiveness of clearance of bacteria and increased susceptibility to systemic infection.10-12 Patients who have undergone liver or pancreatic surgery with or without bilioenteric bypass may develop postoperative bile leaks requiring biliary drainage for diversion of bile from the leaking site. These patients may also develop anastamotic strictures.
Technique Biliary obstruction is divided into “low” and “high” bile duct obstruction. Low bile duct obstruction occurs below the usual insertion of the cystic duct (Fig. 1). Preprocedure determination of the level of bile duct obstruction has important therapeutic and prognostic implications. In low bile duct obstruction complete drainage of the entire biliary tree can be accomplished by a single, well-placed catheter or stent because the obstruction is below the confluence of right and left bile ducts. Low bile duct obstruction is best treated endoscopically to avoid the risks associated with percutaneous drainage and nuisance of an external catheter.13 When an endoscopic approach is not technically pos-
Percutaneous drainage
15 secondary ducts as well. When bile segments are isolated, a single drainage catheter cannot effectively drain the entire biliary tree. In our practice, the term complete isolation describes the situation in which cholangiography does not result in any opacification of the isolated system(s), effective isolation refers to the situation in which isolated ducts are opacified with contrast during cholangiography, but do not drain, and impending isolation describes the situation in which a biliary radical is opacified and drains but has a central narrowing that is likely to progress and cause effective or complete isolation in the foreseeable future (Fig. 2). Effective and impending isolation increase the risk of subsequent episodes of cholangitis. High bile duct obstruction is best approached percutaneously, because a specific duct can be targeted to maximize drainage of functional parenchyma based on preprocedure imaging. Percutaneous access allows for easier and more reliable targeting than an endoscopic approach.
Preprocedure Evaluation Imaging
Figure 1 (A) Cholangiogram with drainage catheter in place demonstrates low bile duct obstruction. The common hepatic duct (arrow) is patent and there is occlusion of the common bile duct (arrowhead) by a pancreatic carcinoma. (B) After catheter placement, all bile segments are adequately drained.
sible, a percutaneous approach to low bile duct obstruction is indicated. High bile duct obstruction occurs above the cystic duct insertion. In 1975, Bismuth and Corlette classified carcinomas of the hepatic confluence as Type I, Type II, and Type III. Type I tumors involve the common hepatic duct, but do not involve the confluence of the right and left hepatic ducts. In Type II tumors there is obstruction of the primary confluence, and Type III extends to involve either the right or left secondary confluence. Some authors have described a Type IV, in which the tumor involves the secondary confluences on the right or left sides. When the obstruction is above the hilus, as is often the case in cholangiocarcinoma there is frequently isolation of the right and left hepatic ducts that may extend to involve the
The importance of high quality, current imaging for use in procedure planning in patients with bile duct obstruction can not be overemphasized. The level of obstruction is most easily determined by thin section CT or magnetic resonance cholangiopancreatography (MRCP). Three-dimensional reconstructions may make it easier to appreciate the level of bile duct obstruction and normal variants of biliary anatomy that are seen in up to 20% of patients. CT and MR also provide an assessment of the functional hepatic parenchyma. Functional parenchyma is that part of the liver that is not replaced by tumor and has an intact portal venous supply. The portal vein provides 80% of the blood supply to the normal liver parenchyma. Portal vein occlusion eventually results in atrophy of the affected segment or segments, particularly when the ipsilateral bile duct is also occluded.14 Drainage of a portion of the liver without an intact portal venous blood supply will not result in improvement of liver function, just as placing a nephrostomy tube into an atrophic kidney or a kidney with an occluded renal artery would not be expected to result in improvement of kidney function. Ultrasound is useful to determine portal vein patency, the presence of biliary dilation, and intraductal tumor but is itself not usually adequate for procedure planning.
Antibiotics Preprocedure broad spectrum antibiotic prophylaxis is given to all patients undergoing biliary drainage because transient bacteremia commonly occurs during the procedure, even in the absence of signs or symptoms of infection. Appropriate postprocedure coverage may then be determined based on bile cultures obtained at the time of drainage.
Procedural Issues Approach As discussed earlier, a percutaneous approach is preferable in the setting of high bile duct obstruction because the specific duct or ducts draining the most functional liver parenchyma
A.M. Covey and K.T. Brown
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duct is longer than the right hepatic duct and therefore less susceptible to isolation. In cases in which segmental isolation of the right sided ducts is suspected, a left-sided approach may provide more benefit. In patients with ascites, a leftsided approach is preferable (all other factors being equal) because ascites will often leak around a right-sided catheter causing skin irritation. Because the approach to the left liver is subcostal rather than midaxillary, the volume of pericatheter ascites leaking can be minimized by a left-sided drainage.
Image Guidance Biliary drainage is most often performed using fluoroscopic guidance. Ultrasound can be helpful for the initial puncture when the bile ducts are dilated. Radio-opaque landmarks may be present from prior surgery and can be helpful in triangulating a specific bile duct. This is particularly important when bile duct isolation is suspected, and every attempt is made to avoid contaminating regions of the biliary tree that will not be drained.
Sedation Biliary drainage is performed with conscious sedation, often with short-acting benzodiazepines and narcotics. In our practice we use midazolam and either merperidin or fentanyl citrate. Patients should abstain from oral intake (be nil per os) or be on a clear liquid diet for at least 4 hours before the procedure. Patients should be well hydrated and have working venous access for sedation and antibiotic prophylaxis.
Access to the Biliary
Figure 2 (A) Biliary drainage in a patient with cholangiocarcinoma demonstrates complete isolation of the opacified right bile ducts and nonvisualized left bile ducts. (B) Cholangiogram in a patient with breast cancer shows impending isolation of the right (arrow) and left (arrowheads) bile ducts. Opacification and incomplete drainage of bile segments can be a source of cholangitis.
may be targeted. Percutaneous drainage is most commonly achieved from the right side, because it is more accessible and the volume of the right liver is usually larger than that of the left. When there is atrophy or compromise of the portal vein on one side, the patient can be expected to derive more benefit from drainage of the contralateral hemiliver. The left hepatic
Classical teaching has been to approach the right hemiliver from the 11th intercostal space in the midaxillary line and on the left from three finger breadths below the xyphoid.15 With modern imaging techniques, it is more appropriate to plan the approach based on the targeted duct, or—in the phrase commonly attributed to Willie Sutton—to “go where the money is.” For example, when the left hemiliver is hypertrophic, a left intercostal approach may be more an appropriate than a subxyphoid approach. If the target duct is posterior, an approach more posterior than the midaxillary line may be more successful. Once the site for dermatotomy is chosen, it is prepped, draped, and anesthetized. A 22- or 21-gauge double-walled needle such as the Chiba is advanced into the parenchyma of the liver. With the stylet removed, contrast may be gingerly injected while the needle is retracted until a bile duct is opacified (Fig. 3A). If the target duct is opacified, and the puncture is peripheral, it may be used for the drainage (Fig. 3B). Peripheral access is preferred because the risk of bleeding and inadequate drainage rises with a central access. If, however, a central duct is opacified, contrast is injected to opacify the peripheral ducts, allowing for a more suitable access site to be punctured. Once the target duct is accessed with the needle, the needle is exchanged for a coaxial system to upsize the 0.018-inch access guide wire to an 0.035 guide wire. Technical details on accessing the biliary tract with needles and wires are discussed in the this issue. Through the larger system, a directional catheter is inserted and ad-
Percutaneous drainage
17
Figure 3 (A) To access a bile duct, a needle is advanced into the liver and contrast injected as the needle is withdrawn. (B) The needle is exchanged over a wire for a coaxial dilator. (C) A Kumpe catheter is advanced beyond the obstruction of the common hepatic duct and finally exchanged for a multiside hole drainage catheter (D) with sideholes positioned above and below the obstruction.
vanced over a hydrophilic wire beyond the obstruction (Fig. 3C) and into the small bowel. The catheter can then be exchanged over a stiffer wire (eg, Amplatz) for a multiside hole drainage catheter (Fig. 3D). This type of catheter is referred to as an “internal– external” catheter because it allows bile to drain both externally into a bag and also internally into the small bowel, thereby preserving the normal enterohepatic circulation of bile. When placing this type of catheter, it is critical to choose (or create) a catheter with the appropriate number and length of side holes above and below the obstruction to provide adequate drainage. If a catheter cannot be advanced beyond the obstruction into the small bowel, an obligatory external drainage catheter may be placed (Fig. 4). Finally, a self-expanding metallic stent is a third option
for drainage (Fig. 5). The advantage of a stent is the ability to reestablish patency of the occluded duct(s), allowing for internal drainage of bile into the bowel without an external device. Because most metallic stents cannot be easily removed, surgeons often prefer that a metallic stent not be placed in patients who are candidates for resection. Stents are associated with a mean patency of 6 to 9 months and therefore their use is usually reserved for patients with limited life expectancy.16-19 In patients with longer life expectancy, stent placement may be considered if the patient understands that the likelihood of requiring reintervention is high. Stent placement in high bile duct obstruction makes further percutaneous intervention more difficult, and stents should only be placed after all targeted segments have been drained.
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A.M. Covey and K.T. Brown anastamosis in OLT or at the cut edge in split liver transplants. Drainage in these cases can be very challenging because the bile ducts are not dilated because of the low resistance drainage pathway provided by the leak. Although not commonly used today because they are considered a source of bile leaks, a T-tube may be present in some cases. When a T-tube is present, one operator can inject contrast into the T-tube to opacify and distend the intrahepatic bile ducts while a second operator punctures the opacified target duct. A bile leak may result in a biloma that requires percutaneous drainage. Once the biloma resulting from a leak has been drained, injection of the catheter may result in opacification
Figure 4 (A) Cholangiogram in a patient with cholangiocarcinoma demonstrates effective isolation of the right and left bile ducts. Obstruction of the common hepatic duct could not be crossed and (B) a right-to-left external drainage catheter was placed.
Accessing the Nondilated Biliary System Percutaneous drainage of a nondilated biliary tree can be technically challenging. Technical details on accessing the biliary tract with needles and wires are discussed in this issue. Usually this occurs in the setting of an orthotopic liver transplants (OLT), postoperative bile leak, or PSC. Options for surgical reconstruction after liver transplant include choledochocholedochostomy (CC) and Roux-en-Y choledochojejunostomy (CJ). CC entails an end-to-end anastamosis of the donor and recipient ducts and is generally preferred, because it preserves a functional sphincter and allows for future endoscopic access. In split-liver, living donor, or pediatric transplants, a CJ may be necessary because of the size discrepancy between the donor and recipient ducts. When the disease necessitating transplant involves the common duct, as with PSC or cholangiocarcinoma, a CJ is also necessary. The most common biliary complications after transplant are leaks and strictures. Leaks most commonly occur at the
Figure 5 (A) Low bile duct obstruction in a patient with pancreatic cancer treated with a self-expanding metallic stent positioned (B) below the insertion of cystic duct. Incidental note is made of a common bile duct anomaly in which the right posterior sector duct (arrow) drains into the left hepatic duct (arrowhead).
Percutaneous drainage
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Postprocedure Care and Complications Patients should be monitored carefully for 24 hours after drainage for signs of bleeding or sepsis. With proper technique, including peripheral bile duct puncture, serious bleeding complications are uncommon. Since the hepatic artery, portal vein, and bile duct travel side by side within portal triads, it is not uncommon for blood to enter the bile duct during catheter exchanges, resulting in transient hemobilia. New or persistent hemobilia after exchange is often due to a sidehole of the catheter becoming positioned in an adjacent portal or hepatic vein branch and can be corrected simply by repositioning the catheter. Persistent venous bleeding from the tract may require upsizing of the catheter to tamponade the bleeding site. When a patient develops bleeding 1 to 2 weeks or more after biliary drainage, or pulsatile bleeding with sudden onset, particularly when there is not only hemobilia, but also bleeding around the catheter, arterial injury should be suspected and the patient should undergo hepatic angiography and embolization of the offending arterial branch.20 Any ab-
Figure 6 Two biloma drainage catheters were placed in a patient with a persistent bile leak after resection of a hepatic hemangioma. After resolution of the biloma cavity, contrast injection demonstrates the communication with the biliary tree (arrow) (A). The biliary tract was catheterized from the biloma and an internal external biliary drainage catheter was successfully placed (B).
of the intrahepatic duct. In this case, the duct may be cannulated through the biloma, converting the biloma drainage catheter to a biliary drainage catheter (Fig. 6). Alternatively, the biloma drainage catheter can be injected to opacify the intrahepatic ducts to allow puncture for access. In some cases percutaneous access may not be possible and, after multiple unsuccessful passes, the risk/benefit ratio of pursuing access should be reassessed.
Figure 7 (A) Selective right posterior hepatic artery injection in a patient with hemobilia 1 month after drainage shows a pseudoaneurysm (arrow) overlying the biliary drainage catheter. This artery was selectively embolized with microcoils (B) and the hemobilia resolved.
20 normality of a hepatic arterial branch adjacent to the biliary drainage catheter should be taken as presumptive evidence of injury to the branch (Fig. 7). Despite prophylactic antibiotic coverage, sepsis may be seen immediately after drainage or within several hours.21 Continued administration of appropriate antibiotics, expansion of intravascular volume, and pressor support are used as necessary. Blood cultures should be drawn to identify organisms responsible for bacteremia. Cultures of bile at the time of drainage should be routinely sent in patients with fever, bilioenteric anastomosis or sphincterotomy, previous ERCP, or an indwelling stent or catheter. Up to 5% of patients with no history of fever, previous biliary surgery, or either endoscopic or percutaneous intervention will have positive cultures.22
References 1. Jarnagin WR, Burke E, Powers C, et al: Intrahepatic biliary enteric bypass provides effective palliation in selected patients with malignant obstruction at the hepatic duct confluence. Am J Surg 175:453-460, 1998 2. House MG, Choti MA: Palliative therapy for pancreatic/biliary cancer. Surg Oncol Clin North Am 13:491-503, 2004 3. Shankar A, Taylor I: Clinical examination and investigation, in Surgery of the Liver and Biliary Tract (ed 3). Philadelphia, PA, Saunders, 2000 4. Bartholomew TC, Summerfield JA, Billing BH, et al: Bile acid profiles of human serum and skin interstitial fluid and their relationship to pruritus studied by gas chromatography-mass spectrometry. Clin Sci (Lond) 63:65-73, 1982 5. Abraham NS, Barkun JS, Barkun AN: Palliation of malignant biliary obstruction: A prospective trial examining impact on quality of life. Gastrointest Endosc 56:835-841, 2002 6. Ballinger AB, McHugh M, Catnach SM, et al: Symptom relief and quality of life after stenting for malignant bile duct obstruction. Gut 35:467470, 1994 7. Van Laethem JL, De Broux S, Eisendrath P, et al: Clinical impact of biliary drainage and jaundice resolution in patients with obstructive metastases at the hilum. Am J Gastroenterol 98:1271-1277, 2003 8. Padillo FJ, Andicoberry B, Naranjo A, et al: Anorexia and the effect of internal biliary drainage on food intake in patients with obstructive jaundice. J Am Coll Surg 192:584-590, 2001
A.M. Covey and K.T. Brown 9. 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 10. Clements WD, McCaigue M, Erwin P, et al: Biliary decompression promotes Kupffer cell recovery in obstructive jaundice. Gut 38:925931, 1996 11. Katz S, Yang R, Rodefeld MJ, et al: Impaired hepatic bacterial clearance is reversed by surgical relief of obstructive jaundice. J Pediatr Surg 26:401-405; discussion 405-406, 1991 12. Vane DW, Redlich P, Weber T, et al: Impaired immune function in obstructive jaundice. J Surg Res 45:287-293, 1988 13. Rerknimitr R, Kladcharoen N, Mahachai V, et al: Result of endoscopic biliary drainage in hilar cholangiocarcinoma. J Clin Gastroenterol 38: 518-523, 2004 14. Hann LE, Getrajdman GI, Brown KT, et al: Hepatic lobar atrophy: Association with ipsilateral portal vein obstruction. Am J Roentgenol 167:1017-1021, 1996 15. Venbrux A, Osterman F: Malignant obstruction of the hepatobiliary system, in Baum S, Pentecost MJ, eds: Abrams’ Angiography. New York, NY, Little, Brown, 1997, pp 472-482 16. Lee BH, Choe DH, Lee JH, et al: Metallic stents in malignant biliary obstruction: Prospective long-term clinical results. Am J Roentgenol 168:741-745, 1997 17. Mathieson JR, McLoughlin RF, Cooperberg PL, et al: Malignant obstruction of the common bile duct: Long-term results of GianturcoRosch metal stents used as initial treatment. Radiology 192:663-667, 1994 18. Wagner HJ, Knyrim K, Vakil N, et al: Plastic endoprostheses versus metal stents in the palliative treatment of malignant hilar biliary obstruction: A prospective and randomized trial. Endoscopy 25:213-218, 1993 19. Inal M, Akgül E, Aksungur E, et al: Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction: Complications, follow-up and reintervention in 154 patients. Acta Radiol 44: 139-146, 2003 20. Winick AB, Waybill PN, Venbrux AC: Complications of percutaneous transhepatic biliary interventions. Tech Vasc Interv Radiol 4:200-206, 2001 21. Smith TP, Ryan JM: Sepsis in the interventional radiology patient. J Vasc Interv Radiol 15:317-325, 2004 22. Brody LA, Brown KT, Getrajdman GI, et al: Clinical factors associated with positive bile cultures during primary percutaneous biliary drainage. J Vasc Interv Radiol 9:572-578, 1998
O
ver the past three decades, endoscopic and percutaneous biliary drainage have become readily available in most hospital settings and these minimally invasive techniques have revolutionized the treatment of patients with biliary obstruction. In the past, treatment of biliary obstruction had required surgery under general anesthesia and an extended hospital stay.1 Currently, the same patient can most often be treated either endoscopically as an outpatient or during a short hospital stay after percutaneous drainage under moderate sedation. The purpose of this article is to review the indications and technique of percutaneous transhepatic cholangiography and biliary drainage.
Indication for Biliary Drainage Before committing a patient to any invasive procedure, it is important to have a clearly defined goal.2 Biliary intervention, like any invasive procedure, may have complications and external catheters require maintenance and impact lifestyle. Signs and symptoms of biliary obstruction vary depending on the disease process, history of prior intervention, and comorbidities. Clinical jaundice is common with a serum bilirubin over 3 mg/dL.3 Pruritus is a common symptom in patients with biliary obstruction. Pruritus is often out of proportion to the serum bilirubin level and bile acid profile4 and the pathogenesis is poorly understood. Pruritus can have a pronounced deleterious effect on quality of life and is usually relieved by drainage of even a single liver segment.5-7
Weill Medical College of Cornell University, Memorial Hospital, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. Address reprint requests to: Anne M. Covey, MD, Memorial Sloan-Kettering Cancer, Department of Radiology, 1275 York Avenue, New York, NY 10021. E-mail: [email protected].
14
1089-2516/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.tvir.2008.05.003
Patients with obstructive jaundice may also complain of alteration in taste of food or frank anorexia that is relieved with re-establishment of the normal enterohepatic circulation of bile.8 Cholangitis almost always occurs in the setting of a previously instrumented or manipulated biliary tree resulting from direct or enteric contamination of an obstructed system.9 The inciting event is most commonly iatrogenic— endoscopic retrograde chlangiopancreatography (ERCP), sphincterotomy, or surgery— but occasionally cholangitis occurs because of colonized gallstones or an enteric fistula. Cholestasis may affect the function of Kupfer cells resulting in decreased effectiveness of clearance of bacteria and increased susceptibility to systemic infection.10-12 Patients who have undergone liver or pancreatic surgery with or without bilioenteric bypass may develop postoperative bile leaks requiring biliary drainage for diversion of bile from the leaking site. These patients may also develop anastamotic strictures.
Technique Biliary obstruction is divided into “low” and “high” bile duct obstruction. Low bile duct obstruction occurs below the usual insertion of the cystic duct (Fig. 1). Preprocedure determination of the level of bile duct obstruction has important therapeutic and prognostic implications. In low bile duct obstruction complete drainage of the entire biliary tree can be accomplished by a single, well-placed catheter or stent because the obstruction is below the confluence of right and left bile ducts. Low bile duct obstruction is best treated endoscopically to avoid the risks associated with percutaneous drainage and nuisance of an external catheter.13 When an endoscopic approach is not technically pos-
Percutaneous drainage
15 secondary ducts as well. When bile segments are isolated, a single drainage catheter cannot effectively drain the entire biliary tree. In our practice, the term complete isolation describes the situation in which cholangiography does not result in any opacification of the isolated system(s), effective isolation refers to the situation in which isolated ducts are opacified with contrast during cholangiography, but do not drain, and impending isolation describes the situation in which a biliary radical is opacified and drains but has a central narrowing that is likely to progress and cause effective or complete isolation in the foreseeable future (Fig. 2). Effective and impending isolation increase the risk of subsequent episodes of cholangitis. High bile duct obstruction is best approached percutaneously, because a specific duct can be targeted to maximize drainage of functional parenchyma based on preprocedure imaging. Percutaneous access allows for easier and more reliable targeting than an endoscopic approach.
Preprocedure Evaluation Imaging
Figure 1 (A) Cholangiogram with drainage catheter in place demonstrates low bile duct obstruction. The common hepatic duct (arrow) is patent and there is occlusion of the common bile duct (arrowhead) by a pancreatic carcinoma. (B) After catheter placement, all bile segments are adequately drained.
sible, a percutaneous approach to low bile duct obstruction is indicated. High bile duct obstruction occurs above the cystic duct insertion. In 1975, Bismuth and Corlette classified carcinomas of the hepatic confluence as Type I, Type II, and Type III. Type I tumors involve the common hepatic duct, but do not involve the confluence of the right and left hepatic ducts. In Type II tumors there is obstruction of the primary confluence, and Type III extends to involve either the right or left secondary confluence. Some authors have described a Type IV, in which the tumor involves the secondary confluences on the right or left sides. When the obstruction is above the hilus, as is often the case in cholangiocarcinoma there is frequently isolation of the right and left hepatic ducts that may extend to involve the
The importance of high quality, current imaging for use in procedure planning in patients with bile duct obstruction can not be overemphasized. The level of obstruction is most easily determined by thin section CT or magnetic resonance cholangiopancreatography (MRCP). Three-dimensional reconstructions may make it easier to appreciate the level of bile duct obstruction and normal variants of biliary anatomy that are seen in up to 20% of patients. CT and MR also provide an assessment of the functional hepatic parenchyma. Functional parenchyma is that part of the liver that is not replaced by tumor and has an intact portal venous supply. The portal vein provides 80% of the blood supply to the normal liver parenchyma. Portal vein occlusion eventually results in atrophy of the affected segment or segments, particularly when the ipsilateral bile duct is also occluded.14 Drainage of a portion of the liver without an intact portal venous blood supply will not result in improvement of liver function, just as placing a nephrostomy tube into an atrophic kidney or a kidney with an occluded renal artery would not be expected to result in improvement of kidney function. Ultrasound is useful to determine portal vein patency, the presence of biliary dilation, and intraductal tumor but is itself not usually adequate for procedure planning.
Antibiotics Preprocedure broad spectrum antibiotic prophylaxis is given to all patients undergoing biliary drainage because transient bacteremia commonly occurs during the procedure, even in the absence of signs or symptoms of infection. Appropriate postprocedure coverage may then be determined based on bile cultures obtained at the time of drainage.
Procedural Issues Approach As discussed earlier, a percutaneous approach is preferable in the setting of high bile duct obstruction because the specific duct or ducts draining the most functional liver parenchyma
A.M. Covey and K.T. Brown
16
duct is longer than the right hepatic duct and therefore less susceptible to isolation. In cases in which segmental isolation of the right sided ducts is suspected, a left-sided approach may provide more benefit. In patients with ascites, a leftsided approach is preferable (all other factors being equal) because ascites will often leak around a right-sided catheter causing skin irritation. Because the approach to the left liver is subcostal rather than midaxillary, the volume of pericatheter ascites leaking can be minimized by a left-sided drainage.
Image Guidance Biliary drainage is most often performed using fluoroscopic guidance. Ultrasound can be helpful for the initial puncture when the bile ducts are dilated. Radio-opaque landmarks may be present from prior surgery and can be helpful in triangulating a specific bile duct. This is particularly important when bile duct isolation is suspected, and every attempt is made to avoid contaminating regions of the biliary tree that will not be drained.
Sedation Biliary drainage is performed with conscious sedation, often with short-acting benzodiazepines and narcotics. In our practice we use midazolam and either merperidin or fentanyl citrate. Patients should abstain from oral intake (be nil per os) or be on a clear liquid diet for at least 4 hours before the procedure. Patients should be well hydrated and have working venous access for sedation and antibiotic prophylaxis.
Access to the Biliary
Figure 2 (A) Biliary drainage in a patient with cholangiocarcinoma demonstrates complete isolation of the opacified right bile ducts and nonvisualized left bile ducts. (B) Cholangiogram in a patient with breast cancer shows impending isolation of the right (arrow) and left (arrowheads) bile ducts. Opacification and incomplete drainage of bile segments can be a source of cholangitis.
may be targeted. Percutaneous drainage is most commonly achieved from the right side, because it is more accessible and the volume of the right liver is usually larger than that of the left. When there is atrophy or compromise of the portal vein on one side, the patient can be expected to derive more benefit from drainage of the contralateral hemiliver. The left hepatic
Classical teaching has been to approach the right hemiliver from the 11th intercostal space in the midaxillary line and on the left from three finger breadths below the xyphoid.15 With modern imaging techniques, it is more appropriate to plan the approach based on the targeted duct, or—in the phrase commonly attributed to Willie Sutton—to “go where the money is.” For example, when the left hemiliver is hypertrophic, a left intercostal approach may be more an appropriate than a subxyphoid approach. If the target duct is posterior, an approach more posterior than the midaxillary line may be more successful. Once the site for dermatotomy is chosen, it is prepped, draped, and anesthetized. A 22- or 21-gauge double-walled needle such as the Chiba is advanced into the parenchyma of the liver. With the stylet removed, contrast may be gingerly injected while the needle is retracted until a bile duct is opacified (Fig. 3A). If the target duct is opacified, and the puncture is peripheral, it may be used for the drainage (Fig. 3B). Peripheral access is preferred because the risk of bleeding and inadequate drainage rises with a central access. If, however, a central duct is opacified, contrast is injected to opacify the peripheral ducts, allowing for a more suitable access site to be punctured. Once the target duct is accessed with the needle, the needle is exchanged for a coaxial system to upsize the 0.018-inch access guide wire to an 0.035 guide wire. Technical details on accessing the biliary tract with needles and wires are discussed in the this issue. Through the larger system, a directional catheter is inserted and ad-
Percutaneous drainage
17
Figure 3 (A) To access a bile duct, a needle is advanced into the liver and contrast injected as the needle is withdrawn. (B) The needle is exchanged over a wire for a coaxial dilator. (C) A Kumpe catheter is advanced beyond the obstruction of the common hepatic duct and finally exchanged for a multiside hole drainage catheter (D) with sideholes positioned above and below the obstruction.
vanced over a hydrophilic wire beyond the obstruction (Fig. 3C) and into the small bowel. The catheter can then be exchanged over a stiffer wire (eg, Amplatz) for a multiside hole drainage catheter (Fig. 3D). This type of catheter is referred to as an “internal– external” catheter because it allows bile to drain both externally into a bag and also internally into the small bowel, thereby preserving the normal enterohepatic circulation of bile. When placing this type of catheter, it is critical to choose (or create) a catheter with the appropriate number and length of side holes above and below the obstruction to provide adequate drainage. If a catheter cannot be advanced beyond the obstruction into the small bowel, an obligatory external drainage catheter may be placed (Fig. 4). Finally, a self-expanding metallic stent is a third option
for drainage (Fig. 5). The advantage of a stent is the ability to reestablish patency of the occluded duct(s), allowing for internal drainage of bile into the bowel without an external device. Because most metallic stents cannot be easily removed, surgeons often prefer that a metallic stent not be placed in patients who are candidates for resection. Stents are associated with a mean patency of 6 to 9 months and therefore their use is usually reserved for patients with limited life expectancy.16-19 In patients with longer life expectancy, stent placement may be considered if the patient understands that the likelihood of requiring reintervention is high. Stent placement in high bile duct obstruction makes further percutaneous intervention more difficult, and stents should only be placed after all targeted segments have been drained.
18
A.M. Covey and K.T. Brown anastamosis in OLT or at the cut edge in split liver transplants. Drainage in these cases can be very challenging because the bile ducts are not dilated because of the low resistance drainage pathway provided by the leak. Although not commonly used today because they are considered a source of bile leaks, a T-tube may be present in some cases. When a T-tube is present, one operator can inject contrast into the T-tube to opacify and distend the intrahepatic bile ducts while a second operator punctures the opacified target duct. A bile leak may result in a biloma that requires percutaneous drainage. Once the biloma resulting from a leak has been drained, injection of the catheter may result in opacification
Figure 4 (A) Cholangiogram in a patient with cholangiocarcinoma demonstrates effective isolation of the right and left bile ducts. Obstruction of the common hepatic duct could not be crossed and (B) a right-to-left external drainage catheter was placed.
Accessing the Nondilated Biliary System Percutaneous drainage of a nondilated biliary tree can be technically challenging. Technical details on accessing the biliary tract with needles and wires are discussed in this issue. Usually this occurs in the setting of an orthotopic liver transplants (OLT), postoperative bile leak, or PSC. Options for surgical reconstruction after liver transplant include choledochocholedochostomy (CC) and Roux-en-Y choledochojejunostomy (CJ). CC entails an end-to-end anastamosis of the donor and recipient ducts and is generally preferred, because it preserves a functional sphincter and allows for future endoscopic access. In split-liver, living donor, or pediatric transplants, a CJ may be necessary because of the size discrepancy between the donor and recipient ducts. When the disease necessitating transplant involves the common duct, as with PSC or cholangiocarcinoma, a CJ is also necessary. The most common biliary complications after transplant are leaks and strictures. Leaks most commonly occur at the
Figure 5 (A) Low bile duct obstruction in a patient with pancreatic cancer treated with a self-expanding metallic stent positioned (B) below the insertion of cystic duct. Incidental note is made of a common bile duct anomaly in which the right posterior sector duct (arrow) drains into the left hepatic duct (arrowhead).
Percutaneous drainage
19
Postprocedure Care and Complications Patients should be monitored carefully for 24 hours after drainage for signs of bleeding or sepsis. With proper technique, including peripheral bile duct puncture, serious bleeding complications are uncommon. Since the hepatic artery, portal vein, and bile duct travel side by side within portal triads, it is not uncommon for blood to enter the bile duct during catheter exchanges, resulting in transient hemobilia. New or persistent hemobilia after exchange is often due to a sidehole of the catheter becoming positioned in an adjacent portal or hepatic vein branch and can be corrected simply by repositioning the catheter. Persistent venous bleeding from the tract may require upsizing of the catheter to tamponade the bleeding site. When a patient develops bleeding 1 to 2 weeks or more after biliary drainage, or pulsatile bleeding with sudden onset, particularly when there is not only hemobilia, but also bleeding around the catheter, arterial injury should be suspected and the patient should undergo hepatic angiography and embolization of the offending arterial branch.20 Any ab-
Figure 6 Two biloma drainage catheters were placed in a patient with a persistent bile leak after resection of a hepatic hemangioma. After resolution of the biloma cavity, contrast injection demonstrates the communication with the biliary tree (arrow) (A). The biliary tract was catheterized from the biloma and an internal external biliary drainage catheter was successfully placed (B).
of the intrahepatic duct. In this case, the duct may be cannulated through the biloma, converting the biloma drainage catheter to a biliary drainage catheter (Fig. 6). Alternatively, the biloma drainage catheter can be injected to opacify the intrahepatic ducts to allow puncture for access. In some cases percutaneous access may not be possible and, after multiple unsuccessful passes, the risk/benefit ratio of pursuing access should be reassessed.
Figure 7 (A) Selective right posterior hepatic artery injection in a patient with hemobilia 1 month after drainage shows a pseudoaneurysm (arrow) overlying the biliary drainage catheter. This artery was selectively embolized with microcoils (B) and the hemobilia resolved.
20 normality of a hepatic arterial branch adjacent to the biliary drainage catheter should be taken as presumptive evidence of injury to the branch (Fig. 7). Despite prophylactic antibiotic coverage, sepsis may be seen immediately after drainage or within several hours.21 Continued administration of appropriate antibiotics, expansion of intravascular volume, and pressor support are used as necessary. Blood cultures should be drawn to identify organisms responsible for bacteremia. Cultures of bile at the time of drainage should be routinely sent in patients with fever, bilioenteric anastomosis or sphincterotomy, previous ERCP, or an indwelling stent or catheter. Up to 5% of patients with no history of fever, previous biliary surgery, or either endoscopic or percutaneous intervention will have positive cultures.22
References 1. Jarnagin WR, Burke E, Powers C, et al: Intrahepatic biliary enteric bypass provides effective palliation in selected patients with malignant obstruction at the hepatic duct confluence. Am J Surg 175:453-460, 1998 2. House MG, Choti MA: Palliative therapy for pancreatic/biliary cancer. Surg Oncol Clin North Am 13:491-503, 2004 3. Shankar A, Taylor I: Clinical examination and investigation, in Surgery of the Liver and Biliary Tract (ed 3). Philadelphia, PA, Saunders, 2000 4. Bartholomew TC, Summerfield JA, Billing BH, et al: Bile acid profiles of human serum and skin interstitial fluid and their relationship to pruritus studied by gas chromatography-mass spectrometry. Clin Sci (Lond) 63:65-73, 1982 5. Abraham NS, Barkun JS, Barkun AN: Palliation of malignant biliary obstruction: A prospective trial examining impact on quality of life. Gastrointest Endosc 56:835-841, 2002 6. Ballinger AB, McHugh M, Catnach SM, et al: Symptom relief and quality of life after stenting for malignant bile duct obstruction. Gut 35:467470, 1994 7. Van Laethem JL, De Broux S, Eisendrath P, et al: Clinical impact of biliary drainage and jaundice resolution in patients with obstructive metastases at the hilum. Am J Gastroenterol 98:1271-1277, 2003 8. Padillo FJ, Andicoberry B, Naranjo A, et al: Anorexia and the effect of internal biliary drainage on food intake in patients with obstructive jaundice. J Am Coll Surg 192:584-590, 2001
A.M. Covey and K.T. Brown 9. 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 10. Clements WD, McCaigue M, Erwin P, et al: Biliary decompression promotes Kupffer cell recovery in obstructive jaundice. Gut 38:925931, 1996 11. Katz S, Yang R, Rodefeld MJ, et al: Impaired hepatic bacterial clearance is reversed by surgical relief of obstructive jaundice. J Pediatr Surg 26:401-405; discussion 405-406, 1991 12. Vane DW, Redlich P, Weber T, et al: Impaired immune function in obstructive jaundice. J Surg Res 45:287-293, 1988 13. Rerknimitr R, Kladcharoen N, Mahachai V, et al: Result of endoscopic biliary drainage in hilar cholangiocarcinoma. J Clin Gastroenterol 38: 518-523, 2004 14. Hann LE, Getrajdman GI, Brown KT, et al: Hepatic lobar atrophy: Association with ipsilateral portal vein obstruction. Am J Roentgenol 167:1017-1021, 1996 15. Venbrux A, Osterman F: Malignant obstruction of the hepatobiliary system, in Baum S, Pentecost MJ, eds: Abrams’ Angiography. New York, NY, Little, Brown, 1997, pp 472-482 16. Lee BH, Choe DH, Lee JH, et al: Metallic stents in malignant biliary obstruction: Prospective long-term clinical results. Am J Roentgenol 168:741-745, 1997 17. Mathieson JR, McLoughlin RF, Cooperberg PL, et al: Malignant obstruction of the common bile duct: Long-term results of GianturcoRosch metal stents used as initial treatment. Radiology 192:663-667, 1994 18. Wagner HJ, Knyrim K, Vakil N, et al: Plastic endoprostheses versus metal stents in the palliative treatment of malignant hilar biliary obstruction: A prospective and randomized trial. Endoscopy 25:213-218, 1993 19. Inal M, Akgül E, Aksungur E, et al: Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction: Complications, follow-up and reintervention in 154 patients. Acta Radiol 44: 139-146, 2003 20. Winick AB, Waybill PN, Venbrux AC: Complications of percutaneous transhepatic biliary interventions. Tech Vasc Interv Radiol 4:200-206, 2001 21. Smith TP, Ryan JM: Sepsis in the interventional radiology patient. J Vasc Interv Radiol 15:317-325, 2004 22. Brody LA, Brown KT, Getrajdman GI, et al: Clinical factors associated with positive bile cultures during primary percutaneous biliary drainage. J Vasc Interv Radiol 9:572-578, 1998