Percutaneous Biliary Interventions: Inside and Outside the Box: Percutaneous Management of Benign Biliary Strictures

Benign biliary strictures are often due to a variety of etiologies, most of which are iatrogenic. Clinical presentation can vary from asymptomatic disease with elevated liver enzymes to obstructive jaundice and recurrent cholangitis. Diagnostic imaging methods, such as ultrasound, multidetector computed tomography, and magnetic resonance imaging (cholangiopancreatography), are used to identify stricture location, extent, and possible source of biliary obstruction. The management of benign biliary strictures requires a multidisciplinary team approach and include endoscopic, percutaneous, and surgical interventions. Percutaneous biliary interventions provide an alternative diagnostic and therapeutic approach, especially in patients who are not amenable to endoscopic evaluation. This review provides an overview of benign biliary strictures and percutaneous management by interventional radiologists. Diagnostic evaluation with percutaneous transhepatic cholangiography and treatment options, including biliary drainage, balloon dilation, retrievable/biodegradable stents, and other innovative minimally invasive options, are discussed.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Percutaneous Biliary Endoscopy

Biliary endoscopy is underutilized by interventional radiologists and has the potential to become an effective adjunctive tool to help both diagnose and treat a variety of biliary pathology. This is particularly true in cases where endoscopic retrograde cholangiopancreatography fails or is not feasible due to surgically altered anatomy. Both preoperative clinical and technical procedural factors must be taken into consideration prior to intervention. In this article, clinical evaluation, perioperative management, and procedural techniques for percutaneous biliary endoscopy are reviewed.     

Percutaneous Biliary Interventions: Inside and Outside the Box: The Role of the Interventional Radiologist in Bile Leak Diagnosis and Management

Bile leaks are rare but potentially devastating iatrogenic or posttraumatic complications. This is being diagnosed more frequently since the advent of laparoscopic cholecystectomy and propensity toward nonsurgical management in select trauma patients. Timely recognition and accurate characterization of a bile leak is crucial for favorable patient outcomes and involves a multimodal imaging approach. Management is driven by the type and extent of the biliary injury and requires multidisciplinary cooperation between interventional radiologists, endoscopists, and hepatobiliary/transplant surgeons. Interventional radiologists have a vital role in both the diagnosis and management of bile leaks. Percutaneous interventional procedures aid in the characterization of a bile leak and in its initial management via drainage of fluid collections. Most bile leaks resolve with decompression of the biliary system which is routinely done via endoscopic retrograde cholangiopancreaticography. Some bile leaks can be definitively treated percutaneously while others necessitate surgical repair. The primary principle of percutaneous management is flow diversion away from the site of a leak with the placement of transhepatic biliary drainage catheters. While this can be accomplished with relative ease in some cases, others call for more advanced techniques. Bile duct embolization or sclerosis may also be required in cases where a leaking bile duct is isolated from the main biliary tree.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Gallbladder: Role of Interventional Radiology

Percutaneous cholecystostomy is an established procedure for the management of patients with acute cholecystitis and with significant medical comorbidities that would make laparoscopic cholecystectomy excessively risky. In this review, we will explore the role of percutaneous cholecystostomy in the management of acute cholecystitis as well as other applications in the management of biliary pathology. The indications, grading, technical considerations, and postprocedure management in the setting of acute cholecystitis are discussed. In addition, we will discuss the potential role of percutaneous cholecystostomy in the management of gallstones and biliary strictures, in establishing internal biliary drainage, and in a joint setting with other clinicians such as gastroenterologists in the management of complex biliary pathology.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Complications of Percutaneous Biliary Procedures

Percutaneous biliary and gallbladder drainage is routinely performed by interventional radiology. These pathologies and techniques are well described in the literature and in this issue. The purpose of this review is to focus on the recognition and management of complications. Percutaneous biliary drains can have a variety of complications which can range from minor skin issues to more serious and complex bleeding issues. Advancements in imaging and techniques improve the safety profile of percutaneous biliary and gallbladder interventions.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Biliary Anatomy

The hepatobiliary system is known to have high anatomic variability, as studies have shown variant rates of over 40% among individuals. This review will describe biliary anatomy and the most common anatomic variants, knowledge of which is critical to ensuring safe and effective biliary interventions.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Future Directions of Percutaneous Biliary Interventions

We are at an exciting cross-road in biliary interventions. While other services such as surgery and gastroenterology have learned to use imaging guidance to improve the safety and efficacy of their procedures, it is time for interventional radiologist to learn endoscopic interventions to achieve the same. The future of interventional radiologists in managing patients with biliary disease depends on (1) increasing comfort of our procedures, (2) publishing our data on biliary interventions, and (3) increasing collaboration with other services to manage biliary disease. We need to appropriately understand the limitations of interventional radiology to help guide the future directions of our specialty in this very interesting space.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Role of Interventional Radiology in Children with Biliary and Gallbladder Diseases

Biliary and gallbladder diseases in infants and children often present unique diagnostic and therapeutic challenges that require a fundamental understanding of notable biliary diseases and anatomical variations. Surgical and endoscopic approaches that are often the gold standard in adult biliary treatment may be technically challenging and are associated with a high morbidity that may warrant a multidisciplinary treatment approach. This article will provide a comprehensive overview of the biliary conditions where interventional radiology can play a vital role in the diagnosis, management, and treatment. Differences in approach or technique between children and adults will be highlighted.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Role of Interventional Radiology in the Management of Acute Cholangitis

Acute cholangitis presents with a wide severity spectrum and can rapidly deteriorate from local infection to multiorgan failure and fatal sepsis. The pathophysiology, diagnosis, and general management principles will be discussed in this review article. The focus of this article will be on the role of biliary drainage performed by interventional radiology to manage acute cholangitis. There are specific scenarios where percutaneous drainage should be preferred over endoscopic drainage. Percutaneous transhepatic and transjejunal biliary drainage are both options available to interventional radiology. Additionally, interventional radiology is now able to manage these patients beyond providing acute biliary drainage including cholangioplasty, stenting, and percutaneous cholangioscopy/biopsy.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Treatment of Malignant Bile Duct Obstruction: What the Interventional Radiologist Needs to Know

Management of malignant bile duct obstruction is both a clinically important and technically challenging aspect of caring for patients with advanced malignancy. Bile duct obstruction can be caused by extrinsic compression, intrinsic tumor/stone/debris, or by biliary ischemia, inflammation, and sclerosis. Common indications for biliary intervention include lowering the serum bilirubin level for chemotherapy, ameliorating pruritus, treating cholangitis or bile leak, and providing access for bile duct biopsy or other adjuvant therapies. In some institutions, biliary drainage may also be considered prior to hepatic or pancreatic resection. Prior to undertaking biliary intervention, it is essential to have high-quality cross-sectional imaging to determine the level of obstruction, the presence of filling defects or atrophy, and status of the portal vein. High bile duct obstruction, which we consider to be obstruction above, at, or just below the confluence (Bismuth classifications IV, III, II, and some I), is optimally managed percutaneously rather than endoscopically because interventional radiologists can target specific ducts for drainage and can typically avoid introducing enteric contents into isolated undrained bile ducts. Options for biliary drainage include external or internal/external catheters and stents. In the setting of high obstruction, placement of a catheter or stent above the ampulla, preserving the function of the sphincter of Oddi, may lower the risk of future cholangitis by preventing enteric contamination of the biliary tree. Placement of a primary suprapapillary stent without a catheter, when possible, is the procedure most likely to keep the biliary tree sterile.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Biliary Strictures: Etiologies and Medical Management

Biliary strictures have several etiologies that can broadly be classified into benign and malignant causes. The clinical presentation is variable with strictures identified incidentally on imaging or during the evaluation of routine laboratory abnormalities. Symptoms and cholangitis lead to imaging that can diagnose biliary strictures. The diagnosis and medical management of biliary strictures will be discussed in this article.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Noninvasive Imaging Prior to Biliary Interventions

Noninvasive imaging is a crucial and initial step in the diagnostic algorithm of patients with suspected biliary pathology and directs the subsequent diagnostic and therapeutic workup, including the endoluminal and percutaneous biliary interventions. This article reviews the current noninvasive imaging methods for the evaluation of biliary system and further discusses their roles in the diagnostic workup of different biliary disease.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Advancements in Endoscopic Biliary Interventions by Gastroenterology

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing endoscope is guided into the duodenum, allowing for instruments to access the biliary and pancreatic ducts. ERCP was initially developed as a diagnostic tool as computed tomography was in its infancy during that time. ERCP has evolved since its inception in the 1960s to becoming not only a valuable diagnostic resource but now an effective therapeutic intervention in the treatment of various biliary disorders. The most common biliary interventions performed by ERCP include the management of biliary obstructions for benign and malignant indications. Additionally, endoscopic ultrasound (EUS) has been increasingly utilized in diagnosing and intervening on pancreaticobiliary lesion. This article will discuss the various methods currently available for various endoscopic biliary interventions and future interventional techniques. For the management of biliary strictures, EUS can be utilized with fine need aspiration, while ERCP can be used for the placement of various stents and diagnostic modalities. Another example is radiofrequency ablation, which can be used for the treatment of hilar strictures. Achieving bile duct access can be challenging in patients with complicated clinical scenarios; other techniques that can be used for bile duct access include EUS-guided rendezvous approach, transluminal approach, Choleodochoduodenostomy, and hepatogastrostomy, along with gaining access in complicated anatomy such as in patients with Rou-en-Y anatomy. Another useful endoscopic tool is nonsurgical drainage of the gallbladder, which can be a suitable option when patients are not optimal surgical candidates. There has also been an increase in outpatient utilization of ERCP, which was previously seen as a predominantly inpatient procedure in the past. Possible future evolutions of biliary interventions include robotic manipulation of a duodenoscope and direct infusion of chemotherapeutic or immunomodulatory agents into the pancreaticobiliary tree. These advancements will depend on parallel advancements in other imaging and laboratory as well as breakthrough technology or techniques by other disciplines including interventional radiology and minimally invasive surgery.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Biliary Strictures: A Surgeon's Perspective for Interventional Radiologists

Biliary strictures can be a challenging clinical problem to manage and often have unclear etiologies, including benign and malignant causes. Left untreated, these problems can lead to significant morbidity and mortality linked to their underlying diagnosis. The approach to adult patients with biliary strictures requires a multidisciplinary team involving surgeons, interventional endoscopists, and interventional radiologists for diagnosis, symptom relief, palliation, as well as potential curative management. From a surgeon''s perspective, there are many ways to classify and approach these strictures. It is of paramount importance to start with an excellent understanding of the patient''s prior surgical history. In approaching a patient with a new diagnosis of biliary stricture, it is also critical to understand its etiology relatively quickly, as 70% are malignant in the adult population. Concurrently, one must clearly define the location and extent of the stricture: intrahepatic, hilar, or distal extrahepatic bile duct, as well as whether it is a singular lesion or multifocal phenotypes. This information provides a path forward in clinical decision-making regarding durability and efficacy of therapy, which is typically aimed at decompression and/or surgical resection to prevent cholangitis, sepsis, and progressive hepatic insufficiency.     

经皮肝穿刺胆道支架植入后再狭窄分析及介入治疗

目的探讨恶性胆道梗阻性黄疸经皮肝穿刺胆道支架置放术后支架再狭窄原因及介入治疗。方法20例胆道支架再狭窄患者,根据术后引流量及黄疸消退情况,于2周,1个月,2个月,3个月复查肝功、血、尿、粪及B超、CT、经引流管胆道造影,确认支架再狭窄性质、部位后,利用外置引流管途径行介入再通治疗。支架均为国产普通镍钛合金胆道支架,直径10mm,长度40~80mm。结果20例支架再狭窄中,9例为肿瘤浸润压迫所致,3例为支架上端成角致阻塞,4例为胆泥及食物残渣或陈旧性凝血块阻塞支架,2例为胆管炎性狭窄,2例为肉芽组织增生引起阻塞。全部再狭窄病例经引流管抽吸、药物灌注、冲洗、导管导丝疏通、球囊扩张、支架再植入予以复通,生存期超过6个月。结论经皮肝穿刺胆道支架植入术治疗恶性胆道梗阻,术后支架再狭窄率仍较高,应引起重视。     

Characteristics and Outcomes of Percutaneous Biliary Interventions in the United States

ObjectiveTo explore baseline characteristics, comorbidities, and clinical diagnoses in the prediction of outcomes for inpatient percutaneous biliary interventions in the United States.MethodsHospitalizations for percutaneous transhepatic cholangiography and percutaneous biliary drainage were studied using the National Inpatient Sample 2012 to 2015. Associations between baseline characteristics, comorbidities, clinical diagnoses, and outcomes were analyzed using multivariable regression modeling. Regional variations were studied in an exploratory analysis.ResultsHospitalizations for percutaneous biliary interventions had average inpatient mortality of 3.8% ± 0.8% and length of stay of 7.6 ± 0.3 days. Hypertension was the most common comorbidity (50.5% ± 0.8%), and paralysis was associated with the highest inpatient mortality (19.1% ± 5.7%) and length of stay (11.4 ± 1.3 days). Compared with nonmalignant biliary-pancreatic disorders, sepsis was associated with the highest inpatient mortality (6.5% ± 1.1%; adjusted odds ratio [aOR]: 5.2 [3.9-7.0]) and length of stay (9.0 ± 3.0 days; aOR: 2.2 [1.9-2.5]), followed by underlying malignancy (mortality of 5.5% ± 0.6%; aOR: 2.3 [1.7-3.0]; length of stay of 8.3 ± 0.2 days; aOR: 1.6 [1.4-1.8]). The observed associations were independent of baseline characteristics and comorbidities. With regard to regional variations, the Middle Atlantic states had the lengthiest hospital stays (38.8% ± 2.0% >8 days) and the East South Central states had the highest inpatient mortality (6.6% ± 1.6%) while having the highest frequency of malignancy (37.9% ± 3.7%) and the lowest frequency of postoperative cases (15.2% ± 2.4%).ConclusionIn addition to baseline characteristics and comorbidities, sepsis and malignancy were determinants of higher mortality and increased length of stay in hospitalizations for percutaneous biliary interventions. We observed significant regional variations in clinical diagnoses and outcomes across the United States.     

Percutaneous Treatment of Extrahepatic Bile Duct Stones Assisted by Balloon Sphincteroplasty and Occlusion Balloon

Objective

To describe the technical feasibility and usefulness of extrahepatic biliary stone removal by balloon sphincteroplasty and occlusion balloon pushing.

Materials and Methods

Fifteen patients with extrahepatic bile duct stones were included in this study. Endoscopic stone removal was not successful in 13 patients, and two patients refused the procedure due to endoscopy phobia. At first, all patients underwent percutaneous transhepatic biliary drainage (PTBD). A few days later, through the PTBD route, balloon assisted dilatation for common bile duct (CBD) sphincter was performed, and then the stones were pushed into the duodenum using an 11.5 mm occlusion balloon. Success rate, reason for failure, and complications associated with the procedure were evaluated.

Results

Eight patients had one stone, five patients had two stones, and two patients had more than five stones. The procedure was successful in 13 patients (13/15). In 12 of the patients, all stones were removed in the first trial. In one patient, residual stones were discovered on follow-up cholangiography, and were subsequently removed in the second trial. Technical failure occurred in two patients. Both of these patients had severely dilated CBD and multiple stones with various sizes. Ten patients complained of pain in the right upper quadrant and epigastrium of the abdomen immediately following the procedure, but there were no significant procedure-related complications such as bleeding or pancreatitis.

Conclusion

Percutaneous extrahepatic biliary stone removal by balloon sphincteroplasty and subsequent stone pushing with occlusion balloon is an effective, safe, and technically feasible procedure which can be used as an alternative method in patients when endoscopic extrahepatic biliary stone removal was not successful.