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Ultrasonically guided cholangiography and bile drainage
I l~row~nd ,n hí<~! & 8101 Vol. Prmted in the U.S.A.
10. No. 5. PP. 617-623.
0301-5629/84
1984
$3.00 + .lO
PergamonPressLtd.
ULTRASONICALLY GUIDED CHOLANGIOGRAPHY AND BILE DRAINAGE? MASATOSHI MAKUUCH& SUSUMU YAMAZAKI, and HIROSHI HASEGAWA Department of Hepatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji Chuoku, Tokyo, Japan 104
Second Department
YASUTSUGU BANDAI and TORU ITO of Surgery, University of Tokyo, 7-3-1 Hongo Bunkyoku, Tokyo, Japan 113
Department of Surgical Gastroenterology,
GORO WATANABE Toranomon Hospital, 2-2-2 Toranomon
Minatoku, Tokyo, Japan 105
Abstract-Ultrasonically guided percutaneous transhepatic cholangiography (UG-PTC), bile drainage (UG-PTBD) and gallbladder drainage procedure (UG-PTGBD), developed by US, were performed in 47, 183 and 36 patients, respectively. In 47 patients UG-PTC was successfully performed 51 times without complications. By UG-PTBD 220 intubations were carried out successfully and four attempts failed (1 .S%). The main complication was that the catheter slipped out from the bile duet. It was experienced 27 times (12.3%) in 23 patients (12.4%) from two to 47 days after intubation. UG-PTGBD was successfully performed 36 times. Bleeding from the catheter was experienced in four patients. However, other complications such as cholascos were not experienced. Due to the development of ultrasonic diagnosis and the UG-PTBD procedure, the indications for percutaneous transhepatic cholangiography (PTC) are now limited. For differentiation of jaundice, ultrasonic examination takes over from PTC. For preparation of PTBD, thin needle cholangiography is no longer necessary because UG-PTBD is a single-step procedure without the need for cholangiography. Therefore, the indication for PTC is limited to patients with partial dilatation of intrahepatic bile ducts without jaundice, for example when only the left hepatic duet is dilated due to hepatolithiasis. Key Wordi: Bile ducts-obstruction, Bile ducts-ultrasound percutaneous cholangiography, Gallbladder.
studies, Liver-biliary
ultrasonography,
Jaundicc,
Liver-
hepatic bile drainage (UG-PTBD) and since July 1979, ultrasonically guided percutaneous transhepatic gallbladder drainage (UG-PTGBD) have been performed (Makuuchi 1980). In the present paper, the procedures are described in detail and their impact on the indication for PTC wil1 be discussed.
INTRODUCTION Large intrahepatic ductal structures such as the hepatic veins and the portal venous branches are clearly seen with ultrasound. The normal intrahepatic bile ducts are too smal1 to be demonstrated except at the porta hepatis. However, if the intrahepatic bile ducts are dilated due to obstruction, they can be clearly seen with ultrasound. Goldberg (1976) introduced the term “Ultrasonic cholangiography” indicating the clearness of the bile duet on the sonogram. The ultrasonically guided puncture technique has been applied for many purposes (Holm and Kristensen 1980). However, the technique was not used for the biliary system until we reported on the ultrasonically guided percutaneous transhepatic cholangiography (UG-PTC) procedure (Makuuchi et al. 1977, 1978). First, experimental studies with swine were performed using a manual compound system, subsequently UG-PTC was carried out in clinical cases in 1976. With the real-time system later used, the needle tip and the guide wire were clearly seen. Since March 1979 ultrasonically guided percutaneous trans-
MATERIALS AND METHODS
Ultrasonically guided percutaneous angiogruphy (UG -PK)
transhepatic chol-
In forty-seven patients in whom dilated bile ducts were demonstrated with ultrasound, UG-PTC was carried out 51 times from October 1976 to July 1983. Diseases of the patients are listed in Table 1. The point for insertion of the needle wes freely chosen where the bile duet was most dilated and closest to the body surface. Moreover, the site of puncture was not influenced by the lung and the ribs. The route for the conventional PTC under X-ray assistance was not used. In patients with al1 parts of the intrahepatic bile ducts dilated, the distal end of the left hepatic duet was selected for puncture from the epigastrium. In patients with dilatation of only part of the intrahepatic bile tree, the dilated bile duet closest to the body surface was punctured, avoiding the gallbladder.
tThis work was supported in part by the Princess Takamatsu Cancer Research Fund and by Grants-in-Aid for Cancer Research from the Ministrv of Health and Welfare. Jaoan. fAuthor to w
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Ultrasound in Medicine and Biology
Table UG-PTC
Disease of Head of Pancreas
Ca.
at Porta
Ca.
of Main Bik
Ca.
of Gallbladder
Ca.
of Duodenal
Table
1
UG- PTBD
Cases 1976-
Ca.
October 1984, Volume 10, Numkr
Duet
Papilla
Choledocholithiasis
Left
7
10
11
1
2
Gallbladder
3
4
Ca.
of Main
Bile
2
2
Ca.
of Head
of Pancreas
7
8
Ca.
of Duodenal
9
9
Stenosis
3
3
Others total
5
5
47
51
Ca.
of Liver
Ca. of Bile dwt at Porta Hepatis Carcinoma Duet
Papilla
Hepatolithiasis
transhepatic bile
UG-PTBD was carried out from March 1979 to July 1983 in 183 patients with dilated bile ducts demonstrated by ultrasound. Diseases of the patients
6
7
2
32
31
15
20
21
5
16
14
3
41
46
2
4
4
0
6
4
3
15
12
2
5
1
4
Benign
4
5
2
30
25
8
4
4
0
174
46
Stricture
Recurrence
or Metastasis of ci 1.
Ultrasonically guided-percutaneous drainage (UG-PTBD)
Right
Inflammatory Mass of Pancreas
Choledocholithiasis
Others
Primarily, a manual compound system with a puncture transducer was used (Makuuchi 1977, 1978) and then in two patients, a linear array real-time transducer was used. Since the end of 1978, an oscillating mechanica1 sector scanner with a puncture adaptor (Saitoh et al. 1979) has been used (Makuuchi 1980). With the manual compound system, the depth of the bile duet was measured on the scan and marked on the puncture needle. After sterilization of the skin surface, the puncture transducer was fixed at the point where the selected bile duet was depicted best. With the patient holding his breath, the puncture needle was inserted to the premarked point. The outer guided needle was used to penetrate the skin and fascia to prevent the needle from deviation by bending. After the bile juice was fully aspirated, the radiopaque dye was injected. With the real-time system, it was much easier to detect the tip of the needle and it was therefore not necessary to mark the depth of the selected bile duet on the needle. After the UG-PTBD procedure was introduced, UG-PTC was not performed as a preparation for bile drainage but was reserved for patients with dilatation of part of the intrahepatic bile tree.
Jul. 1983
Cases
Disease
7
Hepatolithiasis of Hepatojejunostomy
Cases
I‘40.of Intubations
Occasions
Primary Hepatis
2
Mar. 1979-
Jul. 1983
Cases
5
total
183
220
are listed in Table 2. A real-time oscillating sector scanner was used. The needle for PTBD was 17 gauge, 20 cm in length with a curved tip. The guide wire, used first, was a “J” tip (3 mm) and a straight tip, 0.813 mm in diameter and 120 cm long. Then a guide wire with a movable core, J tip (6 mm), 0.9 mm dia. and 80 cm long was used. Dilators from 6 to 8 French were used for dilating the anterior wal1 of the bile duet. The drainage tube was made of 7 and 8 French polyethylene tubing. After examination of the entire biliary system with ultrasound, the puncture site of the bile duet was selected. We choose to insert the needle from the epigastrium into the inferior duet of the left lateral lobe in patients with dilatation of the whole intrahepatic bile tree, because the left side is more readily delineated by ultrasound and peripheral bile ducts on this side are easier to puncture than on the right side. However, if the left lobe was invaded by tumor or if carcinoma of the porta hepatis had invaded the left side much more than the right side, the right hepatic duet was punctured. The bile duet to be punctured was preferably about 6 mm in dia. and as peripheral as possible at the point of entry. After adjusting the scanner to the position at which the puncture line on the oscilloscope intersected the target duet, a smal1 incision was made in the skin, the
Ultrasonically guided cholangiography
abdominal wal1 was penetrated with an outer guide needle and finally, while the patient held his breath the PTBD needle was inserted into the bile duet. Following removal of the stylet, correct positioning of the needle tip was confirmed by the discharge or aspiration of bile and the spring guide wire was inserted under ultrasonic control. After the guide wire was smoothly inserted, the scanner was detached from the PTBD needle, and the course and position of the guide wire was followed by real-time sonography. When it was confirmed that the guide wire had passed far enough into the bile duet, the PTBD needle with the outer guide needle was withdrawn, leaving the wire behind. Then, the anterior wal1 of the bile duet was dilated with dilators, and the drainage tube was advanced as far over the wire as possible. Advancing of the dilator and the drainage tube was monitored by ultrasound and/or fluoroscopy. Following insertion of the drainage tube, the wire was pulled out and bile was fully aspirated. Then, cholangiography was performed via the tube to confirm that the tube was in the correct position. Since March 1981 a silastic balloon catheter was used. In several patients, internal drainage was attempted. Ultrasonically guided-percutaneous bladder drainage (UG-PTGBD)
??MASATOSHI MAKUUCHI et al.
619
Table
3
Cases
UG- PTGBD
1980
Choledocholithiasis
of
Ca. with
7
Common
Chronic
Bile
Dwt
Head
of
Pan-liver
Recurrence
Primary
Pancreas
4
Metastasis of
Gastric
Sclerosing
total
2 2
Pancreatntis
of
1983
Cases
16
Cholecystltis
Ca.
Jul.
NO. of
Disease
Ca.
Cholangitis
4 1 36
due to hepatolithiasis. Any duet could be punctured selectively. In patients with dilatation of part of the intrahepatic bile tree because of stricture, the bile ducts peripheral to the stricture could be punctured and the whole biliary tract be demonstrated by one opacification (Fig. 1).
transhepatic gall-
UG-PTGDB was carried out in 36 patients with a dilated gallbladder from July 1979 to July 1983. Diseases of the patients are listed in Table 3. The gallbladder was punctured from the 7th or the 8th intercostal space or from the right subcostal area through the liver parenchyma. In the first case, a teflon sheathed needle was used and the gallbladder was drained by the sheath. In 18 patients, UG-PTGBD was performed by the same procedure as UG-PTBD and a straight or a pigtail catheter was introduced into the gallbladder. In six patients, a J-shaped catheter with a hard metal stylet was inserted directly into the gallbladder under ultrasonic guidance. A fourth alternative was applied in 11 patients where a 14 gauge teflon sheathed needle was used and a silastic balloon catheter was introduced through the teflon sheath to the gallbladder whereupon the balloon was inflated. RESULTS
UG-PTC
UG-PTC was performed succesfully without complications on 51 occasions in 47 patients. In UG-PTC, the puncture site was mainly from the epigastrium to the left hepatic duet. The right hepatic duet was punctured in patients with obstruction at the porta hepatis or with the dilated right hepatic duet
Fig. 1. UG-PTC for hepatolithiasis. The left hepatic duet is punctured at the distal point of the stricture. Several stones are demonstrated in the left hepatic duet and in the common bile duet. If the conventional PTC from the right intercostal space had been performed, the left bile duet distal to the stricture could not have been opacified and several punctures would have had to be made.
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Ultrasound in Medicine and Biology
october 1984, Volume 10, Number 5
UG-PTBD
UG-PTBD was performed 224 times in 183 patients. In four patients, the guide wire was introduced into the bile duet, but the 7F dilator and the drainage tube did not penetrate the anterior wal1 of the bile duet. Of these, two patients, who had obstruction of the common bile duet, had UG-PTGBD performed. The third patient who had carcinoma in the porta hepatis had the other (right) side of the hepatic duet drained. In the last patient, a catheter was introduced, but bile could not be aspirated. By cholangiography stones in the common bile duet were demonstrated and the catheter was placed outside the bile duet. Cholecystectomy and removal of the stones was performed. Thus, UG-PTBD was successfully performed in 220 intubations out of 224 times (98.2%). In 10 patients with 11 intubations the catheter penetrated the posterior wal1 of the bile duet. This caused no complications, the bile drainage was sufficient and jaundice subsided because the catheter has three side holes and these holes were adjusted to the bile duet. To prevent penetration of the posterior wal1 of the bile duet, the guide wire with core was never advanced when more than slight resistance was felt. In such situations the needle was pulled out 3-5mm. At the same time, the scanner was tilted to an optimum position, i.e. a narrow angle of the needle to the bile duet. Once the guide wire with the core had penetrated the posterior wal1 of the bile duet, it was virtually impossible to insert the catheter in the bile duet longitudinally. These incomplete intubations happened 11 times out of 220 intubations (5%). With the UG-PTBD procedure, the left lateral bile duet could be drained even in a patient with a large tumour in the right lobe of the liver (Fig. 2). If conventional PTBD had been performed on this patient, not only bile drainage but also thin needle cholangiography would have been unsuccessful. The main complication after drainage was that the catheter slipped out from the bile duet. This happened with 27 catheters in 23 patients (12.3%). Sixteen catheters were reintubated by UG-PTBD in our department and one in another hospital. One catheter was reintubated with the guide wire under fluoroscopy. Eight catheters which slipped out were left in place and followed up. In these eight patients one was operated on due to carcinoma of the porta hepatis 6 days after the catheter slipped out. Another patient was operated on due to choledocholithiasis. The remaining six patients were followed up and the catheter was pulled out several days after confirming the patient had no complications. The drainage tube slipped out from 2 to 47 days after the intubation. The causes were not always clear
Fig. 2. UG-PTBD in a patient with hepatoma and obstructive jaundice. The left lateral-inferior area duet is punctured and drained. The right lobe of the liver and the left media1 segment is occupied by a hepatoma which invades the left lateral segment. If ultrasonically guided puncture technique had not been used, it would have been virtually impossible not only to drain but also to perform thin needle cholangiography.
but most of the patients had either a severe cough, an attack of asthma or intermittent positive pressure breathing for preoperative care or endoscopic examination. To prevent the catheter from slipping out of the bile duet, a 7F and 8F silastic balloon catheter was designed. In 34 out of 39 attempts, the drainage tubes were replaced with the balloon catheter. One tube slipped out (2.9%) due to deflation of the balloon. Because of its softness, the silastic catheter could not be inserted into the bile duet in five patients. Bleeding after the UG-PTBD procedure occurred in 7 patients (3.8%). Four patients had slight bleeding which stopped soon after the drainage. In one patient, the bleeding continued and the bile drainage was not sufficient. Therefore, UG-PTBD was performed again and bleeding stopped 2 days after reintubation. In the other two patients, bleeding started 5 and 7 days after drainage. In one of these patients bleeding continued two days and then stopped. In the other patient, bleeding continued 8 days til1 he expired due to carcinoma of the bile duet. Hypotension after drainage was experienced in 5 patients of whom three used hypertensive drugs. They had also cholangitis but recovered 4,6 and 15 hr later.
Ultrasonically guided cholangiography
Among 183 patients, 19 had suppurative cholangitis. However, endotoxic shock after bile drainage was not experienced. Al1 these UG-PTGBD procedures were successfully performed. Puncture of the gallbladder was much easier than puncture of the intrahepatic bile ducts due to its large size. In patients with carcinoma of the head of the pancreas and pan-liver metastasis, stable bile drainage could be continued until they expired due to carcinoma (Fig. 3). In patients with acute cholecystitis, pure bile could be obtained from the tube several days after drainage and the cystic duet was recanalized (Fig. 4). The main complication after UG-PTGBD was bleeding which was experienced in 4 patients (ll. 1%). In one patient bleeding happened only during the UG-PTGBD procedure and it stopped just after drainage was accomplished. In two, bleeding continued several hours after drainage. In the last case, the catheter was obstructed a few times due to clots of blood. However, blood transfusion was not necessary in any of the four patients. Slipping out of the catheter, hypotension after drainage or cholascos was not experienced in this series.
??MASATOSHIMAKWCHI
621
et al.
a
DISCUSSION
Since Arner et al. (1962) used X-ray television for PTC, the conventional PTC method has generally been used for differentiation of jaundice. However, there are some disadvantages such as: (1) The puncture point and the direction of the needle is determined only by the anatomical estimation of the position of the bile duet. (2) Often more than one puncture is necessary. (3) As the needle may not be directly inserted into the bile duet, cholangiograms obtained are sometimes obscured by the leakage of contrast medium. (4) Selective puncture of the bile duet is very difficult; for example the left hepatic duet puncture by Glenn’s (1962) right lateral approach. The conventional PTC method is a blind puncture under X-ray fluoroscopy, whereas the UG-PTC permits puncture of the bile duet under ultrasonic visualization. Therefore, it is no longer necessary to use the conventional PTC puncture route. The UG-PTC can puncture any bile duet which is visible with ultrasound. Previously, PTC was performed to differentiate whether jaundice was obstructive or not. Now, jaundice is easily differentiated by ultrasound (Goldstein et al. 1977; Conrad 1978; Koenigsberg 1979). Therefore, this indication for PTC has been taken over by ultrasound. Another major indication of PTC was preparation for PTBD. However, as the UG-PTBD method is a single-step procedure without cholangiography, PTC is not indicated for prepara-
b Fig. 3. UG-PTGBD in a patient with carcinoma of the head of the pancreas. (a) The whole liver is invaded by metastases and the intrahepatic bile duet is not much dilated. The bile duet is not smooth due to tumors and the right anterior bile duet is not opacified. (b) In this case, a pig-tail catheter with double loops is introduced into the gallbladder to prevent it from slipping out.
622
Ultrasound in Medicine and Biology
Fig. 4. UG-PTGBD in a patient with postoperative acute cholecystitis. Cholecystography is performed se.veral days after UG-PTGBD. The cystic duet is recanalized and the whole biliary system is opacified.
tion of bile drainage either. If the patient is suspected of having bile duet diseases, we first perform ultrasound examination to determine the degree and localization of bile duet dilatation. If the patient has dilated bile ducts in the entire liver, UG-PTBD is indicated. If the patient has extrahepatic bile duet dilatation, endoscopic retrograde cholangiography is indicated. If the patient has dilatation of part of the intrahepatic bile tree, for example due to congenital cystic dilatation or hepatolithiasis, UG-PTC is indicated. However, if the patient has cholangitis, UG-PTBD is indicated. Therefore, indications of PTC are very few. Actually, since 1979, UG-PTBD has been performed in 183 patients and UG-PTC in only 20 patients. Before the introduction of UG-PTBD almost al1 the 183 patients would have had PTC performed. By the conventional PTBD methods, the direction of needle insertion was limited to horizontal (Ohto 1978) or perpendicular (Takada 1976). However, the UG-PTBD method is not restricted to these two directions and puncture can be performed with a narrow angle to the bile duet. When the bile duet is punctured at a right angle, insertion of the guide wire becomes difficult and sometimes the posterior wal1 of the bile duet is penetrated. This kind of imperfect
October 1984, Volume 10, Number 5
intubation happened in 5% of intubations. In order to avoid this incomplete intubation and to be able to insert the guide wire and the catheter smoothly, a narrow angled puncture of the bile duet is indispensable. For this purpose, as wel1 as for visualization of the needle and the guide wire, a sector scanner is much better than an electronic linear array scanner. For longer intubation in the bile duet, the periphera1 bile duet puncture is necessary, especially in patients with obstruction at the porta hepatis. The caliber of the selected bile duet for puncture depends on the ski11of the operator. The skillful operator can puncture a bile duet 3 or 4mm in diameter. If the operator is less skillful, a bile duet more than 6 mm should be chosen. If the bile duet is more than 10 mm, it is easy to puncture and insert the guide wire and the catheter. With the conventional PTBD methods, it is difficult to puncture a peripheral bile duet e.g. when the left lateral inferior duet branches to the three thinner ducts. The main causes of the catheter slipping out from the bile duet was coughing and deep breathing. The catheter slipped out into the free abdominal cavity due to dislodgement between the abdominal wal1 and the liver surface. At first, a loop of the tube is formed between the liver and the abdominal wal1 and then the top of the tube slips out of the bile duet. Therefore, it is important to minimize the length of the catheter in the abdominal cavity during respiration. For this purpose, puncturing should be performed at the mid point of breathing. Puncturing when a patient inspires deeply should be avoided. As the UG-PTBD method is a single-step procedure without cholangiography, intraductal pressure is not raised by the injection of contrast medium, so that UG-PTBD is safer in patients with suppurative cholangitis. In this series, 5 patients got hypotension after the drainage procedure but no endotoxic shock was experienced. Takada was the first (1974) to perform PTBD in a patient with suppurative cholangitis in Japan and emphasized that PTBD was not contraindicated in cholangitis. However, 4 out of 24 patients with suppurative cholangitis were lost in his series due to endotoxic shock (Takada 1978). It is quite clear that the UG-PTBD method is much safer than the conventional two-step procedure. The left bile duet was punctured and intubated 174 times out of 220 (79%). With the left sided approach, the puncture site is not disturbed by the ribs and the large bile duet is closer to the skin surface than on the right side. So more peripheral bile ducts can be punctured with the left sided approach. Moreover, as the movements of the liver with respiration are less than on the right side, slipping out of the drainage
Ultrasonically guided cholangiography
tube can be minimized. For these reasons, we prefer the left side approach. Other merits of UG-PTBD are; (1) Puncture of the thick blood vessels can be avoided because ultrasound can demonstrate the vessels simultaneously. (2) Irradiation can be avoided or minimized. (3) UG-PTBD can be performed in the patient’s room if desired. The disadvantages of UG-PTBD are; (1) Training of doctors in real-time scanning is necessary. (2) An appropriate real-time system with puncture attachment must be available. The gallbladder drainage is useful not only for patients with common bile duet obstruction, but also acute cholecystitis. The gallbladder drainage is much easier than the drainage of the bile duet, but it was not performed until 1979. This is due to the fact that puncture of the gallbladder in some cases resulted in bile peritonitis. However, if the intravesical pressure is made negative by a bile drainage procedure, bile leakage wil1 never occur. In patients with suppurative cholecystitis and in poor risk patients, UG-PTGBD is useful. By UG-PTGBD, the patient’s condition becomes much better and recanalization to the main bile duet happens in almost al1 patients. So, the total biliary system can be visualized by injection of contrast material into the drainage tube. In patients with postoperative acute cholecystitis, the gallbladder can be preserved. However, in one patient, stones developed in the gallbladder several months after the catheter was withdrawn. Most larger institutions in Japan which previously performed PTC and PTBD now use the ultrasonically guided puncture technique.
??MASATOSHI MAKUUCHIet al.
623
REEERENCES Amer O., Hagberg S. and Seldinger S. 1. (1962) Percutaneous transhepatic cholangiography. Surgery 52, 561-571. Borow M. (1964) Percutaneous transhepatic cholangiography. The American Surgeon 30, 530-538.
Conrad M. R., Landay M. J. and Janes J. 0. (1978) Sonographic “parallel Channel” sign of biliary tree enlargement in mild to moderate obstructive jaundice. Am. J. Roentgenol. 130,279-286. Glenn F., Evans J. A., Mujahed Z., et al. (1962). Percutaneous transhepatic cholangiography. Ann. Surg. 165, 451462. Goldberg B. B. (1976) Ultrasonic cholangiography. Rndiology 118, 401-404.
Goldstein L. I., Sample W. F., Kade11 B. M., et al. (1977). Gray scale ultrasonography and thin-needle cholangiography. JAMA 238, 1041-1044. Holm H. H. and Kristensen J. K. (1980) Ultrasonicolly Guided Puncture Technique. Munksgaard, Copenhagen. Koenigsberg M., Wiener S. N. and Walzer A. (1979) The accuracy of sonography in the differential diagnosis of obstructive jaundice: A comparison with cholangiography. Rudiology 133, 157-165.
Makuuchi M., Kamiya K., Beppn T., et al. (1977). Percutaneous transhepatic cholangiography under ultrasonic guidance. Acta Hepatol. Jpn. 18, 435, (in Japanese). Makuuchi M., Beppu T., Kamiya K., et al. (1978) Echo guided percutaneous transhepatic cholangiography with puncture transducer. Jpn. J. Surg. 8, 165-175. Makuuchi M., Bandai Y., Ito T., et al. (1980) Ultrasonically guided percutaneous transhepatic bile drainage; A single-step procedure without cholangiography. Radiology 136, 165-169. Ohto M., Ono T., Tsuchiya Y., et al. (1978) Cholungiography and pancreatography. Igaku-Shoin, Tokyo. Saitoh M., Watanabe H., Ohe H., et al. (1979) Ultrasonic real-time guidance for percutaneous puncture. J. Clin. Ultrasound 7, 269-272.
Takada T., Hanyu F., et al. (1974). Severe choledochocholangitis causing numerous cyst-like hepatic abscesses. International Surg. 59, 180-182.
Takada T., Hanyu F., et al. (1976) Percutaneous transhepatic cholangical drainage: direct approach under fluoroscopic control. J. Surg. Oncol. 8, 83-97. Takada T. (1978) Illusu-ated manual of percutaneous transhepatic cholangiography with drainage. Igaku-Shoin, Tokyo (in Japanese).
10. No. 5. PP. 617-623.
0301-5629/84
1984
$3.00 + .lO
PergamonPressLtd.
ULTRASONICALLY GUIDED CHOLANGIOGRAPHY AND BILE DRAINAGE? MASATOSHI MAKUUCH& SUSUMU YAMAZAKI, and HIROSHI HASEGAWA Department of Hepatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji Chuoku, Tokyo, Japan 104
Second Department
YASUTSUGU BANDAI and TORU ITO of Surgery, University of Tokyo, 7-3-1 Hongo Bunkyoku, Tokyo, Japan 113
Department of Surgical Gastroenterology,
GORO WATANABE Toranomon Hospital, 2-2-2 Toranomon
Minatoku, Tokyo, Japan 105
Abstract-Ultrasonically guided percutaneous transhepatic cholangiography (UG-PTC), bile drainage (UG-PTBD) and gallbladder drainage procedure (UG-PTGBD), developed by US, were performed in 47, 183 and 36 patients, respectively. In 47 patients UG-PTC was successfully performed 51 times without complications. By UG-PTBD 220 intubations were carried out successfully and four attempts failed (1 .S%). The main complication was that the catheter slipped out from the bile duet. It was experienced 27 times (12.3%) in 23 patients (12.4%) from two to 47 days after intubation. UG-PTGBD was successfully performed 36 times. Bleeding from the catheter was experienced in four patients. However, other complications such as cholascos were not experienced. Due to the development of ultrasonic diagnosis and the UG-PTBD procedure, the indications for percutaneous transhepatic cholangiography (PTC) are now limited. For differentiation of jaundice, ultrasonic examination takes over from PTC. For preparation of PTBD, thin needle cholangiography is no longer necessary because UG-PTBD is a single-step procedure without the need for cholangiography. Therefore, the indication for PTC is limited to patients with partial dilatation of intrahepatic bile ducts without jaundice, for example when only the left hepatic duet is dilated due to hepatolithiasis. Key Wordi: Bile ducts-obstruction, Bile ducts-ultrasound percutaneous cholangiography, Gallbladder.
studies, Liver-biliary
ultrasonography,
Jaundicc,
Liver-
hepatic bile drainage (UG-PTBD) and since July 1979, ultrasonically guided percutaneous transhepatic gallbladder drainage (UG-PTGBD) have been performed (Makuuchi 1980). In the present paper, the procedures are described in detail and their impact on the indication for PTC wil1 be discussed.
INTRODUCTION Large intrahepatic ductal structures such as the hepatic veins and the portal venous branches are clearly seen with ultrasound. The normal intrahepatic bile ducts are too smal1 to be demonstrated except at the porta hepatis. However, if the intrahepatic bile ducts are dilated due to obstruction, they can be clearly seen with ultrasound. Goldberg (1976) introduced the term “Ultrasonic cholangiography” indicating the clearness of the bile duet on the sonogram. The ultrasonically guided puncture technique has been applied for many purposes (Holm and Kristensen 1980). However, the technique was not used for the biliary system until we reported on the ultrasonically guided percutaneous transhepatic cholangiography (UG-PTC) procedure (Makuuchi et al. 1977, 1978). First, experimental studies with swine were performed using a manual compound system, subsequently UG-PTC was carried out in clinical cases in 1976. With the real-time system later used, the needle tip and the guide wire were clearly seen. Since March 1979 ultrasonically guided percutaneous trans-
MATERIALS AND METHODS
Ultrasonically guided percutaneous angiogruphy (UG -PK)
transhepatic chol-
In forty-seven patients in whom dilated bile ducts were demonstrated with ultrasound, UG-PTC was carried out 51 times from October 1976 to July 1983. Diseases of the patients are listed in Table 1. The point for insertion of the needle wes freely chosen where the bile duet was most dilated and closest to the body surface. Moreover, the site of puncture was not influenced by the lung and the ribs. The route for the conventional PTC under X-ray assistance was not used. In patients with al1 parts of the intrahepatic bile ducts dilated, the distal end of the left hepatic duet was selected for puncture from the epigastrium. In patients with dilatation of only part of the intrahepatic bile tree, the dilated bile duet closest to the body surface was punctured, avoiding the gallbladder.
tThis work was supported in part by the Princess Takamatsu Cancer Research Fund and by Grants-in-Aid for Cancer Research from the Ministrv of Health and Welfare. Jaoan. fAuthor to w
618
Ultrasound in Medicine and Biology
Table UG-PTC
Disease of Head of Pancreas
Ca.
at Porta
Ca.
of Main Bik
Ca.
of Gallbladder
Ca.
of Duodenal
Table
1
UG- PTBD
Cases 1976-
Ca.
October 1984, Volume 10, Numkr
Duet
Papilla
Choledocholithiasis
Left
7
10
11
1
2
Gallbladder
3
4
Ca.
of Main
Bile
2
2
Ca.
of Head
of Pancreas
7
8
Ca.
of Duodenal
9
9
Stenosis
3
3
Others total
5
5
47
51
Ca.
of Liver
Ca. of Bile dwt at Porta Hepatis Carcinoma Duet
Papilla
Hepatolithiasis
transhepatic bile
UG-PTBD was carried out from March 1979 to July 1983 in 183 patients with dilated bile ducts demonstrated by ultrasound. Diseases of the patients
6
7
2
32
31
15
20
21
5
16
14
3
41
46
2
4
4
0
6
4
3
15
12
2
5
1
4
Benign
4
5
2
30
25
8
4
4
0
174
46
Stricture
Recurrence
or Metastasis of ci 1.
Ultrasonically guided-percutaneous drainage (UG-PTBD)
Right
Inflammatory Mass of Pancreas
Choledocholithiasis
Others
Primarily, a manual compound system with a puncture transducer was used (Makuuchi 1977, 1978) and then in two patients, a linear array real-time transducer was used. Since the end of 1978, an oscillating mechanica1 sector scanner with a puncture adaptor (Saitoh et al. 1979) has been used (Makuuchi 1980). With the manual compound system, the depth of the bile duet was measured on the scan and marked on the puncture needle. After sterilization of the skin surface, the puncture transducer was fixed at the point where the selected bile duet was depicted best. With the patient holding his breath, the puncture needle was inserted to the premarked point. The outer guided needle was used to penetrate the skin and fascia to prevent the needle from deviation by bending. After the bile juice was fully aspirated, the radiopaque dye was injected. With the real-time system, it was much easier to detect the tip of the needle and it was therefore not necessary to mark the depth of the selected bile duet on the needle. After the UG-PTBD procedure was introduced, UG-PTC was not performed as a preparation for bile drainage but was reserved for patients with dilatation of part of the intrahepatic bile tree.
Jul. 1983
Cases
Disease
7
Hepatolithiasis of Hepatojejunostomy
Cases
I‘40.of Intubations
Occasions
Primary Hepatis
2
Mar. 1979-
Jul. 1983
Cases
5
total
183
220
are listed in Table 2. A real-time oscillating sector scanner was used. The needle for PTBD was 17 gauge, 20 cm in length with a curved tip. The guide wire, used first, was a “J” tip (3 mm) and a straight tip, 0.813 mm in diameter and 120 cm long. Then a guide wire with a movable core, J tip (6 mm), 0.9 mm dia. and 80 cm long was used. Dilators from 6 to 8 French were used for dilating the anterior wal1 of the bile duet. The drainage tube was made of 7 and 8 French polyethylene tubing. After examination of the entire biliary system with ultrasound, the puncture site of the bile duet was selected. We choose to insert the needle from the epigastrium into the inferior duet of the left lateral lobe in patients with dilatation of the whole intrahepatic bile tree, because the left side is more readily delineated by ultrasound and peripheral bile ducts on this side are easier to puncture than on the right side. However, if the left lobe was invaded by tumor or if carcinoma of the porta hepatis had invaded the left side much more than the right side, the right hepatic duet was punctured. The bile duet to be punctured was preferably about 6 mm in dia. and as peripheral as possible at the point of entry. After adjusting the scanner to the position at which the puncture line on the oscilloscope intersected the target duet, a smal1 incision was made in the skin, the
Ultrasonically guided cholangiography
abdominal wal1 was penetrated with an outer guide needle and finally, while the patient held his breath the PTBD needle was inserted into the bile duet. Following removal of the stylet, correct positioning of the needle tip was confirmed by the discharge or aspiration of bile and the spring guide wire was inserted under ultrasonic control. After the guide wire was smoothly inserted, the scanner was detached from the PTBD needle, and the course and position of the guide wire was followed by real-time sonography. When it was confirmed that the guide wire had passed far enough into the bile duet, the PTBD needle with the outer guide needle was withdrawn, leaving the wire behind. Then, the anterior wal1 of the bile duet was dilated with dilators, and the drainage tube was advanced as far over the wire as possible. Advancing of the dilator and the drainage tube was monitored by ultrasound and/or fluoroscopy. Following insertion of the drainage tube, the wire was pulled out and bile was fully aspirated. Then, cholangiography was performed via the tube to confirm that the tube was in the correct position. Since March 1981 a silastic balloon catheter was used. In several patients, internal drainage was attempted. Ultrasonically guided-percutaneous bladder drainage (UG-PTGBD)
??MASATOSHI MAKUUCHI et al.
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Table
3
Cases
UG- PTGBD
1980
Choledocholithiasis
of
Ca. with
7
Common
Chronic
Bile
Dwt
Head
of
Pan-liver
Recurrence
Primary
Pancreas
4
Metastasis of
Gastric
Sclerosing
total
2 2
Pancreatntis
of
1983
Cases
16
Cholecystltis
Ca.
Jul.
NO. of
Disease
Ca.
Cholangitis
4 1 36
due to hepatolithiasis. Any duet could be punctured selectively. In patients with dilatation of part of the intrahepatic bile tree because of stricture, the bile ducts peripheral to the stricture could be punctured and the whole biliary tract be demonstrated by one opacification (Fig. 1).
transhepatic gall-
UG-PTGDB was carried out in 36 patients with a dilated gallbladder from July 1979 to July 1983. Diseases of the patients are listed in Table 3. The gallbladder was punctured from the 7th or the 8th intercostal space or from the right subcostal area through the liver parenchyma. In the first case, a teflon sheathed needle was used and the gallbladder was drained by the sheath. In 18 patients, UG-PTGBD was performed by the same procedure as UG-PTBD and a straight or a pigtail catheter was introduced into the gallbladder. In six patients, a J-shaped catheter with a hard metal stylet was inserted directly into the gallbladder under ultrasonic guidance. A fourth alternative was applied in 11 patients where a 14 gauge teflon sheathed needle was used and a silastic balloon catheter was introduced through the teflon sheath to the gallbladder whereupon the balloon was inflated. RESULTS
UG-PTC
UG-PTC was performed succesfully without complications on 51 occasions in 47 patients. In UG-PTC, the puncture site was mainly from the epigastrium to the left hepatic duet. The right hepatic duet was punctured in patients with obstruction at the porta hepatis or with the dilated right hepatic duet
Fig. 1. UG-PTC for hepatolithiasis. The left hepatic duet is punctured at the distal point of the stricture. Several stones are demonstrated in the left hepatic duet and in the common bile duet. If the conventional PTC from the right intercostal space had been performed, the left bile duet distal to the stricture could not have been opacified and several punctures would have had to be made.
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october 1984, Volume 10, Number 5
UG-PTBD
UG-PTBD was performed 224 times in 183 patients. In four patients, the guide wire was introduced into the bile duet, but the 7F dilator and the drainage tube did not penetrate the anterior wal1 of the bile duet. Of these, two patients, who had obstruction of the common bile duet, had UG-PTGBD performed. The third patient who had carcinoma in the porta hepatis had the other (right) side of the hepatic duet drained. In the last patient, a catheter was introduced, but bile could not be aspirated. By cholangiography stones in the common bile duet were demonstrated and the catheter was placed outside the bile duet. Cholecystectomy and removal of the stones was performed. Thus, UG-PTBD was successfully performed in 220 intubations out of 224 times (98.2%). In 10 patients with 11 intubations the catheter penetrated the posterior wal1 of the bile duet. This caused no complications, the bile drainage was sufficient and jaundice subsided because the catheter has three side holes and these holes were adjusted to the bile duet. To prevent penetration of the posterior wal1 of the bile duet, the guide wire with core was never advanced when more than slight resistance was felt. In such situations the needle was pulled out 3-5mm. At the same time, the scanner was tilted to an optimum position, i.e. a narrow angle of the needle to the bile duet. Once the guide wire with the core had penetrated the posterior wal1 of the bile duet, it was virtually impossible to insert the catheter in the bile duet longitudinally. These incomplete intubations happened 11 times out of 220 intubations (5%). With the UG-PTBD procedure, the left lateral bile duet could be drained even in a patient with a large tumour in the right lobe of the liver (Fig. 2). If conventional PTBD had been performed on this patient, not only bile drainage but also thin needle cholangiography would have been unsuccessful. The main complication after drainage was that the catheter slipped out from the bile duet. This happened with 27 catheters in 23 patients (12.3%). Sixteen catheters were reintubated by UG-PTBD in our department and one in another hospital. One catheter was reintubated with the guide wire under fluoroscopy. Eight catheters which slipped out were left in place and followed up. In these eight patients one was operated on due to carcinoma of the porta hepatis 6 days after the catheter slipped out. Another patient was operated on due to choledocholithiasis. The remaining six patients were followed up and the catheter was pulled out several days after confirming the patient had no complications. The drainage tube slipped out from 2 to 47 days after the intubation. The causes were not always clear
Fig. 2. UG-PTBD in a patient with hepatoma and obstructive jaundice. The left lateral-inferior area duet is punctured and drained. The right lobe of the liver and the left media1 segment is occupied by a hepatoma which invades the left lateral segment. If ultrasonically guided puncture technique had not been used, it would have been virtually impossible not only to drain but also to perform thin needle cholangiography.
but most of the patients had either a severe cough, an attack of asthma or intermittent positive pressure breathing for preoperative care or endoscopic examination. To prevent the catheter from slipping out of the bile duet, a 7F and 8F silastic balloon catheter was designed. In 34 out of 39 attempts, the drainage tubes were replaced with the balloon catheter. One tube slipped out (2.9%) due to deflation of the balloon. Because of its softness, the silastic catheter could not be inserted into the bile duet in five patients. Bleeding after the UG-PTBD procedure occurred in 7 patients (3.8%). Four patients had slight bleeding which stopped soon after the drainage. In one patient, the bleeding continued and the bile drainage was not sufficient. Therefore, UG-PTBD was performed again and bleeding stopped 2 days after reintubation. In the other two patients, bleeding started 5 and 7 days after drainage. In one of these patients bleeding continued two days and then stopped. In the other patient, bleeding continued 8 days til1 he expired due to carcinoma of the bile duet. Hypotension after drainage was experienced in 5 patients of whom three used hypertensive drugs. They had also cholangitis but recovered 4,6 and 15 hr later.
Ultrasonically guided cholangiography
Among 183 patients, 19 had suppurative cholangitis. However, endotoxic shock after bile drainage was not experienced. Al1 these UG-PTGBD procedures were successfully performed. Puncture of the gallbladder was much easier than puncture of the intrahepatic bile ducts due to its large size. In patients with carcinoma of the head of the pancreas and pan-liver metastasis, stable bile drainage could be continued until they expired due to carcinoma (Fig. 3). In patients with acute cholecystitis, pure bile could be obtained from the tube several days after drainage and the cystic duet was recanalized (Fig. 4). The main complication after UG-PTGBD was bleeding which was experienced in 4 patients (ll. 1%). In one patient bleeding happened only during the UG-PTGBD procedure and it stopped just after drainage was accomplished. In two, bleeding continued several hours after drainage. In the last case, the catheter was obstructed a few times due to clots of blood. However, blood transfusion was not necessary in any of the four patients. Slipping out of the catheter, hypotension after drainage or cholascos was not experienced in this series.
??MASATOSHIMAKWCHI
621
et al.
a
DISCUSSION
Since Arner et al. (1962) used X-ray television for PTC, the conventional PTC method has generally been used for differentiation of jaundice. However, there are some disadvantages such as: (1) The puncture point and the direction of the needle is determined only by the anatomical estimation of the position of the bile duet. (2) Often more than one puncture is necessary. (3) As the needle may not be directly inserted into the bile duet, cholangiograms obtained are sometimes obscured by the leakage of contrast medium. (4) Selective puncture of the bile duet is very difficult; for example the left hepatic duet puncture by Glenn’s (1962) right lateral approach. The conventional PTC method is a blind puncture under X-ray fluoroscopy, whereas the UG-PTC permits puncture of the bile duet under ultrasonic visualization. Therefore, it is no longer necessary to use the conventional PTC puncture route. The UG-PTC can puncture any bile duet which is visible with ultrasound. Previously, PTC was performed to differentiate whether jaundice was obstructive or not. Now, jaundice is easily differentiated by ultrasound (Goldstein et al. 1977; Conrad 1978; Koenigsberg 1979). Therefore, this indication for PTC has been taken over by ultrasound. Another major indication of PTC was preparation for PTBD. However, as the UG-PTBD method is a single-step procedure without cholangiography, PTC is not indicated for prepara-
b Fig. 3. UG-PTGBD in a patient with carcinoma of the head of the pancreas. (a) The whole liver is invaded by metastases and the intrahepatic bile duet is not much dilated. The bile duet is not smooth due to tumors and the right anterior bile duet is not opacified. (b) In this case, a pig-tail catheter with double loops is introduced into the gallbladder to prevent it from slipping out.
622
Ultrasound in Medicine and Biology
Fig. 4. UG-PTGBD in a patient with postoperative acute cholecystitis. Cholecystography is performed se.veral days after UG-PTGBD. The cystic duet is recanalized and the whole biliary system is opacified.
tion of bile drainage either. If the patient is suspected of having bile duet diseases, we first perform ultrasound examination to determine the degree and localization of bile duet dilatation. If the patient has dilated bile ducts in the entire liver, UG-PTBD is indicated. If the patient has extrahepatic bile duet dilatation, endoscopic retrograde cholangiography is indicated. If the patient has dilatation of part of the intrahepatic bile tree, for example due to congenital cystic dilatation or hepatolithiasis, UG-PTC is indicated. However, if the patient has cholangitis, UG-PTBD is indicated. Therefore, indications of PTC are very few. Actually, since 1979, UG-PTBD has been performed in 183 patients and UG-PTC in only 20 patients. Before the introduction of UG-PTBD almost al1 the 183 patients would have had PTC performed. By the conventional PTBD methods, the direction of needle insertion was limited to horizontal (Ohto 1978) or perpendicular (Takada 1976). However, the UG-PTBD method is not restricted to these two directions and puncture can be performed with a narrow angle to the bile duet. When the bile duet is punctured at a right angle, insertion of the guide wire becomes difficult and sometimes the posterior wal1 of the bile duet is penetrated. This kind of imperfect
October 1984, Volume 10, Number 5
intubation happened in 5% of intubations. In order to avoid this incomplete intubation and to be able to insert the guide wire and the catheter smoothly, a narrow angled puncture of the bile duet is indispensable. For this purpose, as wel1 as for visualization of the needle and the guide wire, a sector scanner is much better than an electronic linear array scanner. For longer intubation in the bile duet, the periphera1 bile duet puncture is necessary, especially in patients with obstruction at the porta hepatis. The caliber of the selected bile duet for puncture depends on the ski11of the operator. The skillful operator can puncture a bile duet 3 or 4mm in diameter. If the operator is less skillful, a bile duet more than 6 mm should be chosen. If the bile duet is more than 10 mm, it is easy to puncture and insert the guide wire and the catheter. With the conventional PTBD methods, it is difficult to puncture a peripheral bile duet e.g. when the left lateral inferior duet branches to the three thinner ducts. The main causes of the catheter slipping out from the bile duet was coughing and deep breathing. The catheter slipped out into the free abdominal cavity due to dislodgement between the abdominal wal1 and the liver surface. At first, a loop of the tube is formed between the liver and the abdominal wal1 and then the top of the tube slips out of the bile duet. Therefore, it is important to minimize the length of the catheter in the abdominal cavity during respiration. For this purpose, puncturing should be performed at the mid point of breathing. Puncturing when a patient inspires deeply should be avoided. As the UG-PTBD method is a single-step procedure without cholangiography, intraductal pressure is not raised by the injection of contrast medium, so that UG-PTBD is safer in patients with suppurative cholangitis. In this series, 5 patients got hypotension after the drainage procedure but no endotoxic shock was experienced. Takada was the first (1974) to perform PTBD in a patient with suppurative cholangitis in Japan and emphasized that PTBD was not contraindicated in cholangitis. However, 4 out of 24 patients with suppurative cholangitis were lost in his series due to endotoxic shock (Takada 1978). It is quite clear that the UG-PTBD method is much safer than the conventional two-step procedure. The left bile duet was punctured and intubated 174 times out of 220 (79%). With the left sided approach, the puncture site is not disturbed by the ribs and the large bile duet is closer to the skin surface than on the right side. So more peripheral bile ducts can be punctured with the left sided approach. Moreover, as the movements of the liver with respiration are less than on the right side, slipping out of the drainage
Ultrasonically guided cholangiography
tube can be minimized. For these reasons, we prefer the left side approach. Other merits of UG-PTBD are; (1) Puncture of the thick blood vessels can be avoided because ultrasound can demonstrate the vessels simultaneously. (2) Irradiation can be avoided or minimized. (3) UG-PTBD can be performed in the patient’s room if desired. The disadvantages of UG-PTBD are; (1) Training of doctors in real-time scanning is necessary. (2) An appropriate real-time system with puncture attachment must be available. The gallbladder drainage is useful not only for patients with common bile duet obstruction, but also acute cholecystitis. The gallbladder drainage is much easier than the drainage of the bile duet, but it was not performed until 1979. This is due to the fact that puncture of the gallbladder in some cases resulted in bile peritonitis. However, if the intravesical pressure is made negative by a bile drainage procedure, bile leakage wil1 never occur. In patients with suppurative cholecystitis and in poor risk patients, UG-PTGBD is useful. By UG-PTGBD, the patient’s condition becomes much better and recanalization to the main bile duet happens in almost al1 patients. So, the total biliary system can be visualized by injection of contrast material into the drainage tube. In patients with postoperative acute cholecystitis, the gallbladder can be preserved. However, in one patient, stones developed in the gallbladder several months after the catheter was withdrawn. Most larger institutions in Japan which previously performed PTC and PTBD now use the ultrasonically guided puncture technique.
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Takada T., Hanyu F., et al. (1976) Percutaneous transhepatic cholangical drainage: direct approach under fluoroscopic control. J. Surg. Oncol. 8, 83-97. Takada T. (1978) Illusu-ated manual of percutaneous transhepatic cholangiography with drainage. Igaku-Shoin, Tokyo (in Japanese).