Technical note: Percutaneous transhepatic removal of biliary endoprostheses using a snare

A method using a snare for the percutaneous transhepatic removal of occluded or malpostioned biliary endoprostheses is described. This technique was used in two patients. In one, the snared endoprosthesis was pulled into the duodenum, while in the second patient the prosthesis was pulled out through transhepatic tract without complications.     

Percutaneous transhepatic techniques for removal of endoscopically placed biliary plastic endoprostheses

Endoscopic retrograde cholangiopancreatography-placed plastic biliary endoprostheses can migrate proximally and become impacted (4.9%). Endoscopy is resorted to first and percutaneous transhepatic techniques are resorted to second. Percutaneous transhepatic techniques are resorted to in probably less that 0.5% of all endoscopic retrograde cholangiopancreatography-placed plastic biliary endoprostheses and are rarely reported. The current article reviews the results, various techniques, and potential complications during the percutaneous transhepatic removal of these endoprostheses.     

Percutaneous transhepatic biliary drainage

Percutaneous transhepatic biliary drainage is performed for the relief of biliary obstruction, usually on a malignant basis. The basic pathology and indications for the procedure are discussed, and the technical materials and methods are detailed. The role of the radiologic technologist in performing this procedure is emphasized.     

Percutaneous transhepatic biliary drainage

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.     

Percutaneous transhepatic internal drainage using polyurethane double-pigtail endoprostheses

Relief of obstructive jaundice by the percutaneous transhepatic insertion of an endoprosthesis is now a well recognised and common radiological procedure. We report the successful insertion of polyurethane double-pigtail stents (made for transpapillary endoscopic insertion) by the percutaneous transhepatic route in five patients. Our experience indicates that these stents are as effective in relieving jaundice as, and less traumatic and easier to insert than, the larger varieties in common use.     

Percutaneous management of occluded biliary duct endoprostheses

Purpose: To present interventional methods for percutaneous treatment of patients with occluded bile duct endoprostheses.Material and Methods: Thirteen patients with endoscopically inserted occluded or damaged bile duct endoprostheses and recurrent jaundice were treated percutaneously. Endoscopic treatment was not available in 2 cases and unsuccessful in 11 other patients. Eleven interventions were performed under systemic sedation and local anaesthesia and 2 under general anaesthesia. The endoprostheses were dislodged to the bowel using different interventional devices. Adequate bile duct drainage was subsequently achieved by insertion of self-expanding metallic stents.Results: All procedures were accomplished successfully and without immediate serious complications. Two metallic stents and 18 plastic endoprostheses were dislodged to the bowel using percutaneous interventional techniques. One plastic endoprosthesis became bent in the duodenum and had to be removed endoscopically due to abdominal pain. None of the other endoprostheses left in the bowel caused any symptoms. Two patients died during the first week after the procedure due to progressive liver failure.Conclusion: Occluded bile duct endoprostheses can be safely dislodged to the bowel and replaced by metallic stents using percutaneous interventional techniques.     

Percutaneous transhepatic bilioplasty: long-term results

We report the results of a long-term follow-up of 40/101 patients with benign biliary strictures treated with percutaneous balloon dilatation (PBD) at the Radiology Department of the University of Turin, from March 1983 to March 1990. We excluded all the patients who were not followed or treated after June 1988, being their follow-up shorter than 18 months. All patients underwent accurate clinical, biological (AST, ALT, gammaGT, alcaline phosphatase) and US controls. Mean follow-up was 33.5 months. Mean success rate was 75% in strictures of bilioenteric anastomosis, 86% in iatrogenic strictures of the common bile duct, 65% in sclerosing cholangitis, 80% in papillary strictures in which endoscopic treatment had not been possible for anatomical reasons. Our results, compared to the most important radiological and surgical series, show PBD to have lower morbidity than surgery and no mortality during the so-called peroperative period (30 days). Moreover, in case of recurrences, PBD can be repeated without further complications and does not affect eventual surgery.     

Percutaneous transhepatic biliary drainage. Complications and their treatment

In the present series of 296 PTBDs in 281 patients, 103 complications of different degree developed (34.7%). Early complications directly connected to the procedure (32/296 = 10.8%) and late complications generally due to malfunctioning of the catheter or progression of the disease (71/296 = 23.9%) are analyzed. Caveats to prevent complications, therapeutic procedures to resolve them, as well as obtained results are reported. On the whole, major complications directly related to the procedure are present in a small percentage and the procedure appears well tolerated also in patients with poor general conditions.     

Percutaneous transhepatic cholangiography and biliary drainage in pediatric liver transplant patients

OBJECTIVE: In children with liver transplants, percutaneous transhepatic cholangiography has a critical role in evaluation and treatment of biliary complications. The purpose of this study was to evaluate the technical success and complication rates of percutaneous transhepatic cholangiography and biliary drain placement in children who underwent liver transplantation. MATERIALS AND METHODS: Between January 1, 1995 and July 1, 1999, 120 pediatric percutaneous transhepatic cholangiography procedures were performed in 76 patients (34 boys, 42 girls; age range, 5 months to 18 years; mean age, 5.3 years). Patients had received left lateral segment, whole-liver, or split-liver transplant grafts. Retrospective review of all pertinent radiology studies and electronic chart review were performed. RESULTS: A diagnostic cholangiogram was obtained in 96% (115/120) of all procedures and drainage catheter placement was successful in 89% (88/99) of attempts. In patients with nondilated intrahepatic bile ducts, a diagnostic cholangiogram was obtained in 92% (46/50) of procedures, and drainage catheter placement was successful in 76% (19/25) of attempts. Minor complications occurred in 10.8% (13/120) of procedures and included transient hemobilia with mild drop in hematocrit level (n = 2), mild pancreatitis (n = 1), fever with bacteremia (n = 5), and fever with negative blood cultures (n = 5). Major complications occurred in 1.7% (2/120) of procedures and included sepsis (n = 1) and hemoperitoneum requiring immediate surgery (n = 1). CONCLUSION: Percutaneous transhepatic cholangiography and biliary drainage can be performed with high technical success and low complication rates in pediatric liver transplant patients, even in those with nondilated intrahepatic ducts.     

Long-term follow-up in patients with malignant biliary obstruction after percutaneous placement of uncovered wallstent endoprostheses.

PURPOSE: Evaluation of the treatment of malignant obstructive jaundice by percutaneous insertion of uncovered stents. MATERIAL AND METHODS: 51 patients (35 men, 16 women) with inoperable malignant biliary obstruction underwent percutaneous placement of uncovered Wallstent biliary endoprostheses. A total of 65 endoprostheses were inserted. RESULTS: The technical success rate was 98%, and the procedure-related complications rate was 10%. Early complications rate within the first 30 days was 2%. The clinical success rate within the first 30 days was 98% and the 30-day mortality rate was 2%. The late complications rate was 16%. The overall stent occlusion rate was 18% at a mean of 288.4 days. Mean survival time of the 50 patients was 214 days, and the mean total duration of hospital stay was 9.8 days. CONCLUSIONS: The advantages of uncovered Wallstent endoprostheses justify their placement in patients with inoperable malignant obstructive jaundice since patients' quality of life is markedly improved. Stent insertion is associated with a low complication rate, most stents remain patent longer than the patients' survival time and patients' hospital stay is relatively short.     

Patency of side branches after peripheral placement of metallic biliary endoprostheses.

During a 28-month period, the authors placed 91 Wallstent endoprostheses in 55 patients with malignant obstructive jaundice. Five patients developed recurrent jaundice between 2 and 60 weeks after stent insertion due to stent occlusion by tumor overgrowth on seven occasions. To assess long-term segmental side-branch drainage through the walls of such endoprostheses, the cholangiograms obtained following stent occlusion were reviewed. In all five patients, evidence of drainage of intrahepatic ducts through the side of the mesh was observed. Although the number of patients in the series is small, this initial experience suggests that long metallic endoprostheses can be placed peripherally in the intrahepatic bile ducts without the potential risk of infection or occlusion of undrained, noninvolved segments. This policy may delay or prevent endoprosthesis occlusion in many patients.     

经皮肝穿胆汁引流治疗肝门胆管癌

目的分析经皮经肝穿刺胆汁引流治疗无法手术的肝门部胆管癌的疗效。方法回顾性分析103例接受经皮经肝穿刺胆汁引流术治疗的肝门部胆管癌所致的梗阻性黄疸患者,经皮经肝穿刺胆管造影后,进行外引流和(或)内外引流、胆道内支架置入术等治疗。临床观察治疗后的近期疗效和生存时间。结果全部患者经皮经肝穿刺胆汁引流手术成功,成功率100%,根据Bismuth分型,其中Ⅰ型30例,Ⅱ型30例,Ⅲ型26例,Ⅳ型17例。留置支架39例,共47枚,引流管64例。治疗后总胆红素明显下降,由(386±162)μmol/L降至(161±117)μmol/L,差异有统计学意义(P<0.01)。术后2周总胆红素较术前明显好转76例,改善15例,无效12例,有效率为88.3%。术前合并感染17例,术后控制13例;术后并发胆道感染15例,胸部感染2例,13例出现一过性血清淀粉酶升高,8例血性引流液,1例胆道出血,1例幽门梗阻,30d内死亡9例。全组生存中位时间186d,1、3、6和12个月生存率分别为89.9%、75.3%、59.6%和16.9%。Ⅰ型、Ⅱ型明显较Ⅲ型、Ⅳ型预后好。结论经皮经肝穿刺胆汁引流术治疗肝门部胆管癌,可明显缓解黄疸,提高患者的生存质量,延长生存时间,为肿瘤进一步治疗提供机会。     

Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement

Bleeding complications occur in 2 to 3% of percutaneous transhepatic biliary drains. These complications include: hemothorax, hemoperitoneum, subcapsular hepatic bleeding, hemobilia, melena, and bleeding from the percutaneous biliary drain. The bleeding sites can be classified into (1) perihepatic bleed sites (hemothorax, hemoperitoneum, subcapsular hepatic hematoma), (2) gastrointestinal bleeding (hemobilia and/or melena), and (3) bleeding from the percutaneous biliary drain itself, which is the most common clinical presentation. There are several bleeding sources. These include skin-bleeds, intercostal artery, portal vein, hepatic vein, and the hepatic artery. There are a variety of maneuvers that can be utilized in the management of bleeding percutaneous biliary drains. These include tractography, angiography, tract embolization, arterial embolization, and tract site changes. This article proposes a protocol for approaching bleeding complications after percutaneous biliary drain placement and details the diagnostic and therapeutic procedures in the management of these bleeding complications.