Endoscopic transpapillary gallbladder drainage for management of acute cholecystitis with coagulopathy

Acute cholecystitis is a common and frequently occurring disease, and laparoscopic cholecystectomy is the preferred treatment method. Percutaneous transhepatic gallbladder drainage is regarded as the first-line palliative procedure for elderly patients with poor cardiopulmonary function who cannot tolerate general anesthesia. However, for patients with acute cholecystitis who are undergoing treatment with oral antithrombotics or who have abnormal coagulation mechanisms, endoscopic transpapillary gallbladder drainage may be a good choice. Endoscopic transpapillary gallbladder drainage is an endoscopic retrograde cholangiopancreatography-based technique that drains the gallbladder by placing a tube into the cavity of the gallbladder though the cystic gall duct. It is the application of the concept of natural orifice transluminal endoscopic surgery in the biliary system. This technique can not only achieve gallbladder drainage but can also minimize the risk of procedure-induced bleeding. In this paper, we describe a representative case to introduce the key points of this procedure and the associated clinical care, hoping to provide useful information for clinicians and nurses.     

Endoscopic nasobiliary drainage in the management of acute cholangitis: an experience in 143 patients

Acute cholangitis is associated with a high mortality and morbidity and often requires drainage of the obstructed biliary system. The purpose of this study was to evaluate the usefulness and safety of endoscopic nasobiliary drainage in the treatment and prevention of acute cholangitis due to diverse etiology. During a 32-month period, 143 patients (67 males, 76 females) with age range of 15 to 84 years underwent urgent fluoroscopy guided endoscopic nasobiliary drainage using a 7 Fr catheter either to treat acute cholangitis not responding to antibiotics (group A, n = 116) or to prevent its development following endoscopic retrograde cholangiography performed in an obstructed biliary system (group B, n = 27). Underlying etiology included bile duct stones (92), malignant biliary obstruction (34), choledochal cyst (4), chronic pancreatitis (4), ruptured hydatid cyst (3), portal hypertensive cholangiopathy (3) and liver abscess (3). Endoscopic nasobiliary drainage was performed successfully in 129 patients (90.2%). Cholangitis improved within 1 to 3 days (in group A) or did not develop (in Group B) in 125 patients (96.7%) with successful endoscopic nasobiliary drainage. Two patients however required additional drainage by percutaneous transhepatic route, while two died inspite of effective endoscopic drainage. Of the 14 patients (9.8%) with failed endoscopic drainage, 9 were managed by surgical decompression or percutaneous transhepatic drainage, 3 died of septicemia. Endoscopic nasobiliary drainage is a safe and effective method to treat patients with acute cholangitis as well as to prevent its development following cholangiography performed in an obstructed biliary system.     

Experience with percutaneous transhepatic cholangiography using the Japanese needle

Percutaneous transhepatic cholangiography using a very thin needle has been performed in 885 patients with a variety of underlying hepatic, biliary, and pancreatic disorders. The procedure was successful in 99% of the patients with dilated intrahepatic bile ducts and in 85% of those with non-dilated ducts. Complications which required surgical intervention occurred only in two cases (0.2%). In patients with obstructive jaundice, external bile drainage was performed immediately after visualization of the bile duct. Percutaneous transhepatic cholangiography is an extremely useful and safe method for investigating disorders of the biliary tract, for localizing the cause of obstructive jaundice, and for reducing the degree of jaundice and improving the general status of patients with obstructive jaundice.     

超声联合透视引导经皮穿刺引流治疗急性胆囊炎

目的：评估经皮穿刺引流治疗急性胆囊炎患者的安全性及有效性.方法：回顾性分析2009-2013年我院118例有急诊胆囊切除禁忌的急性胆囊炎患者在超声联合透视引导下行胆囊穿刺引流术（Percutaneous transhepatic gallbladder drainage,PTGD）.其中急性结石性胆囊炎患者66例,急性非结石性胆囊炎患者52例,通过对比术前、术后实验室、影像学检查及临床症状的改善评价疗效.结果：118例患者中116例为一次性置管成功,有2例患者为二次置管成功.66例急性结石性胆囊炎患者中,45例炎症痊愈,择期行胆囊切除术,12例不能耐受手术患者无症状长期置管,脱管4例,死亡5例.52例非结石性胆囊炎患者中,44例于引流后3～4周透视下行胆道造影示无梗阻后拔管康复,脱管5例,长期带管2例,死亡1例.结论：超声联合透视引导PTGD治疗急性胆囊炎是一种简单、安全而有效的治疗方法,且非结石性胆囊炎患者采用穿刺引流后的预后效果较结石性胆囊炎患者的预后更为显著.     

不同途径胆管支架置入术治疗恶性梗阻性黄疸

目的探讨经皮经肝胆管穿刺引流、内镜逆行胰胆管造影及手术中行胆管支架置入治疗恶性梗阻性黄疸的效果。方法回顾性分析116例行金属胆管支架置入术治疗恶性梗阻性黄疸患者的临床资料。结果经皮经肝胆管穿刺引流置入支架成功率为88.1%,并发症发生率为4.8%,中位生存时间为27周;经内镜逆行胰胆管造影置入支架成功率为86.0%,并发症发生率为5.3%,中位生存时间为25周;手术中胆管支架放置成功率为100%,并发症发生率为13.3%,中位生存时间为23周。结论经皮经肝胆管穿刺引流及经内镜逆行胰胆管造影胆管支架置入术可作为恶性梗阻性黄疸患者姑息性治疗的首选方法。     

Laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for acute cholecystitis in a patient with a left ventricle assist device: A case report and brief review of the literature (with video)

For acute cholecystitis in patients with left ventricular assist devices, the use of percutaneous transhepatic gallbladder drainage to calm inflammation before planned laparoscopic cholecystectomy may be helpful in safely adjusting anticoagulation and in performing safe laparoscopic cholecystectomy, as demonstrated in this case.     

Percutaneous transhepatic sphincterotomy in the management of biliary tract disease

This report describes a novel modification of existing transhepatic techniques and illustrates successful relief of mechanical obstructive jaundice in 2 patients in whom surgical or endoscopic intervention was contraindicated or impossible.In each, percutaneous transhepatic cholangiogram (PTC) was performed in the usual manner. A standard endoscopic papillotome was then advanced across the stricture into the duodenum. Sphincterotomy was performed at the 11 to 1 o'clock position using blended current for 3–4 seconds. Repeat cholangiography showed successful decompression of the biliary tree in both patients. No morbidity or mortality was directly attributable to percutaneous transhepatic sphincterotomy in these patients. This technique offers a safe and therapeutic alternative to biliary tract obstruction, and should be considered in selected patients who are not candidates for surgery or endoscopy.     

彩色多普勒超声引导经皮经肝胆道置管引流

目的 观察彩色多普勒超声引导下经皮经肝胆道置管引流术的成功率、安全性,以及肝功能改善的情况.方法 对151例梗阻性黄疸患者,在超声引导下经皮经肝胆道置管引流,观察胆汁引流情况,有无并发症,以及胆红素降低情况.结果 144例成功置管,失败7例;141例术后引流通畅,胆红素明显降低,3例引流不通畅;术中和术后均未出现大出血、胆汁性腹膜炎、胆管门静脉瘘等并发症.结论 超声引导下经皮经肝胆道置管引流术方法安全、准确,对改善梗阻性黄疸患者的肝肾功能,改善全身状况有积极的作用.     

Microcholecystostomy

Treatment efficacy was compared for transcutaneous transhepatic microcholecystostomy controlled by laparoscopy (75 patients) against that controlled by ultrasound scanning (67 patients) principally in acute cholecystitis. Basic indications for microcholecystostomy are a high operative risk in elderly patients and decompression of the bile ducts for obstructive jaundice. Four patients (2.8%) developed postmicrocholecystostomy complications treated by urgent surgery. The manipulation is short-term, simple and is well tolerated even in grave condition. This makes microcholecystostomy an alternative to cholecystostomy.     

Obstructive jaundice. Nonsurgical options for 'surgical' jaundice.

The development of nonoperative methods of biliary drainage has altered traditional concepts regarding management of medical and surgical jaundice. Patients with newly diagnosed obstructive jaundice typically are elderly and have an unresectable neoplasm. Because surgical cure is often impossible and operation is usually risky in such patients, decompression of the biliary tree by endoscopic retrograde cholangiopancreatography and endoscopically inserted biliary stents has become an increasingly popular means of palliation. Percutaneous transhepatic cholangiography and surgical bilidigestive bypass remain important alternatives. Selection of optimal management for the individual patient requires an in-depth evaluation by a skilled team consisting of the primary care physician, endoscopist, interventional radiologist, and surgeon.     

Prevalence of biliary ascariasis and its relation to biliary lithiasis

Hepatobiliary ultrasound was carried out on 2224 consecutive patients at the Center for Nuclear Medicine and Ultrasound and at one private diagnostic center in Mymensingh for ultrasound examination of different systems. The purpose of this study was to investigate the prevalence of biliary ascariasis and its association with other biliary diseases, specially biliary lithiasis. Data regarding the presence of stone, worm or other diseases were recorded accordingly in this prospective study. There were 952 male and 1272 female patients with an age range of 5–90 years. Biliary diseases were detected in 305 patients (13.71%), of whom 97 were male (10.19%) and 208 were female (16.35%). The most common biliary disease in both sexes was cholelithiasis (11.87%), which was found in 84 male patients (8.82%) and in 180 female patients (14.15%). Other diseases found were choledocholithiasis in 14 patients (3 males, 11 females), gall bladder mass in 9 patients (3 males, 6 females), common bile duct mass in 7 patients (4 male, 3 female) and biliary ascariasis in 10 patients (3 male, 7 female). Overall prevalence of biliary ascariasis was 0.45% (0.31% in male patients and 0.55% in female patients), and age range of patients with the condition was 6–50 years. No case of biliary ascariasis was associated with cholelithiasis or choledocholithiasis. Acute cholecystitis was associated with 8 cases (80%) of biliary ascariasis. Common sonographic findings in patients with biliary ascariasis were a single long, linear or curved echogenic structure within the bile duct, without acoustic shadowing. Other findings were gall bladder distention with sludge inside, an edematous wall and mildly dilated biliary tree. Prevalence of biliary ascariasis in the study was 0.45%, with incidence being higher in female subjects (0.55%). No correlation was found between biliary ascariasis and biliary lithiasis. Most of the cases of biliary ascariasis were associated with acute cholecystitis. We concluded that a careful search for biliary ascariasis should be considered for patients with acute acalculus cholecystitis, especially in areas in which ascariasis is endemic, such as Bangladesh.     

Transhepatic contemporary palliation of biliary and duodenal stenoses by means of metallic stents

We describe the treatment of a stenosing lesion of the horizontal duodenum by means of a large-bore metallic stent inserted percutaneously in a patient with transhepatic biliary drainage. In the same session, we used an expandable metallic stent in the biliary tree to relieve jaundice. We recommend the transhepatic approach for duodenal metallic stent insertion in patients with percutaneous biliary drainage.     

Laparoscopic internal intestinal drainage of bile lakes in a patient with recurrence of jaundice after laparoscopic revision of Kasai portoenterostomy for biliary atresia: A case report

Bile lake, of the postoperative complications after Kasai portoenterostomy (PE) for biliary atresia, causes cholangitis that may induce progressive fibrosis of the liver. Standard treatment for bile lakes has not yet been established, but there are reports that surgical internal intestinal drainage for bile lakes effectively prevents cholangitis and maintains jaundice-free status. In this case, insertion of the percutaneous transhepatic biliary drainage into the bile lake allowed continuous drainage of large volumes of bile juice. However, reoperation following laparotomy increases the surgical risk of subsequent liver transplantation due to postoperative adhesion. Laparoscopic surgery was selected for the patient who was likely to require liver transplantation in the future. In this case, laparoscopic internal intestinal drainage of bile lakes was performed safely by a Cavitron ultrasonic surgical aspirator for the recurrence of jaundice after laparoscopic revision of PE. Cholangitis and jaundice were rapidly resolved after this surgical procedure.     

胰腺癌胆管扩张经超声引导PTBD术(附23例报告)

目的探讨超声引导下PTBD治疗胰腺癌梗阻性黄疸的临床应用价值。方法 23例胰腺癌病人,在超声引导下经皮用 18G针刺入扩张胆管内、通过“J”导丝置入引流管。结果肝总管及左右肝管内置管22支,导管置入失败一支,PTBD成功率96％。讨论超声引导下PTBD定位准确,穿刺时间短,成功率高,是较为安全、有效、病人易接受的胆道减压引流方法。     

Management of patients with malignant obstructive jaundice. Nursing perspective from the interventional radiology room

Most patients with obstructive jaundice caused by primary pancreaticobiliary malignancies and metastatic disease cannot be cured by surgical resection when diagnosed. Biliary drainage in the management of obstructive jaundice therefore represents one of the most important issues in the palliative treatment of these patients. For more than 20 years, percutaneous transhepatic biliary drainage procedures have allowed a nonsurgical approach to the management of malignant biliary obstruction. Improvements in radiologic access systems have extended the use of the percutaneous biliary approach, especially since the advent of metallic stents. Nursing care of these patients before, during, and after the percutaneous biliary intervention is challenging. Patient and family need to be educated about the aim and consequences of the procedure as well as its complications. To care for these patients, the nurse must understand the techniques of percutaneous transhepatic biliary drainage. The purpose of this article is briefly to review the etiology of biliary obstruction, the current treatments to relieve obstructive jaundice, and the basic steps of biliary intervention techniques. The nursing management throughout the procedure, the patient preparation before the procedure, and most importantly, the postprocedural nursing care are discussed.     

介入治疗联合TACE治疗恶性梗阻性黄疸的临床研究

目的临床观察晚期肿瘤患者采用经皮肝穿胆道引流术(PTCD)或/及胆道支架置入术(PTBS)联合区域性肝动脉化疗栓塞术(TACE)治疗梗阻性黄疸的疗效及价值。方法对2012年2月至2013年12月期间病理确诊的36例恶性梗阻性黄疸患者行PTCD或/及PTBS,术后7~14 d患者黄疸减轻后行TACE,临床观察其肝功能变化、近期疗效以及远期并发症、患者生存时间。结果 PTCD术后,36例患者均引流成功,其中26例置入内外引流管+胆道支架,Ⅰ/Ⅱ期共置入网状支架31枚,术后2周内均接受TACE治疗,根据术后复查情况决定下次TACE治疗时间,36例患者共接受TACE 117例次。术后随访3个月、半年、1年的生存率分别为91.6%、75%、47.2%,中位生存期10.1月,除2例引流管脱落外,未见其他严重并发症发生。结论 PTCD或/及PTBS联合TACE对晚期肿瘤患者恶性梗阻性黄疸一种较好的姑息性治疗办法,可明显改善患者症状,提高晚期生活质量。     

Cefamandole bile levels in patients with hepatobiliary disease.

Intraoperative biliary cefamandole concentrations were determined in 16 patients with hepatobiliary pathology. These included seven patients with cholelithiasis, five with acute cholecystitis, two with recurrent ascending cholangitis, and two with liver abscesses. Bile collected 0.5 to 2.5 h after the last antibiotic dose of 1 g administered by intravenous drip showed therapeutically effective concentrations of cefamandole in 84% (11 of 13) of gall bladder samples with a median of 220 micrograms/ml (range, 1.6 to 1,400), and in 100% (13 of 13) of common bile duct samples with a median of 1,100 micrograms/ml (range, 9.0 to greater than 2,000). Only with complete aseptic cystic duct obstruction was cefamandole undetectable in gall bladder bile.     

无钛夹腹腔镜胆囊切除术625例经验

目的探讨无钛夹法处理胆囊管及胆管动脉在腹腔镜胆囊切除术中的应用。方法回顾性分析腹腔镜无钛夹法胆囊切除625例，术中应用超声刀或单极电刀封闭切断胆囊动脉，丝线结扎、套扎器结扎或可吸收夹结扎疸囊管。结果术后无1例病人出现腹腔感染、胆漏和出血等并发症。术后随访1-12个月。未见有腹痛、肩背部疼痛、黄疸及发热等症状。结论腹腔镜胆囊切除术中无钛夹法处理胆囊管及胆管动脉安全、可靠。能避免使用钛夹所致的并发症。     

The role of sonography in imaging of the biliary tract

Sonography is the recommended initial imaging test in the evaluation of patients presenting with right upper quadrant pain or jaundice. Dependent upon clinical circumstances, the differential diagnosis includes choledocholithiasis, biliary stricture, or tumor. Sonography is very sensitive in detection of mechanical biliary obstruction and stone disease, although less sensitive for detection of obstructing tumors, including pancreatic carcinoma and cholangiocarcinoma.In patients with sonographically documented cholelithiasis and choledocholithiasis, laparoscopic cholecystectomy with operative clearance of the biliary stone disease is usually performed. In patients with clinically suspected biliary stone disease, without initial sonographic documentation of choledocholithiasis, endoscopic ultrasound or magnetic resonance cholangiopancreatography is the next logical imaging step. Endoscopic ultrasound documentation of choledocholithiasis in a postcholecystectomy patient should lead to retrograde cholangiography, sphincterotomy, and clearance of the ductal calculi by endoscopic catheter techniques.In patients with clinical and sonographic findings suggestive of malignant biliary obstruction, a multipass contrast-enhanced computed tomography (CT) examination to detect and stage possible pancreatic carcinoma, cholangiocarcinoma, or periductal neoplasm is usually recommended. Assessment of tumor resectability and staging can be performed by CT or a combination of CT and endoscopic ultrasound, the latter often combined with fine needle aspiration biopsy of suspected periductal tumor.In patients whose CT scan suggests hepatic hilar or central intrahepatic biliary tumor, percutaneous cholangiography and transhepatic biliary stent placement is usually followed by brushing or fluoroscopically directed fine needle aspiration biopsy for tissue diagnosis.Sonography is the imaging procedure of choice for biliary tract intervention, including cholecystostomy, guidance for percutaneous transhepatic cholangiography, and drainage of peribiliary abscesses.     

Decreased biliary excretion of piperacillin after percutaneous relief of extrahepatic obstructive jaundice.

The biliary excretion of piperacillin has been assessed in 11 patients with obstructive jaundice due to hilar cholangiocarcinoma. After a 1-g intravenous dose administered 30 min before preliminary percutaneous transhepatic cholangiography, no drug was detected in the bile of seven patients; in four others, drug concentrations were far below the corresponding level in serum. After a period of external biliary drainage of up to 28 days, levels of antibiotic in bile after intravenous administration were only minimally increased. The results suggest that although the impairment of hepatic function may be improved by external biliary decompression when assessed by a fall in plasma bilirubin, the biliary elimination of piperacillin and related beta-lactam antibiotics may remain impaired for prolonged periods.