Interventional radiology of the biliary tract. Transcholecystic intervention

Diagnostic and therapeutic biliary intervention by percutaneous access to the gallbladder is an important new area in interventional radiology. The anatomy of the gallbladder, biliary tree, and surrounding viscera is reviewed in this article as a preliminary to discussion of the diagnostic techniques of aspiration, cholangiography, biopsy, and the therapeutic techniques of gallbladder drainage and cholelithotomy. Recently there has been a bewildering proliferation of procedures aimed at removal, fragmentation, and dissolution of gallbladder stones. Several of these are discussed in this article. Removal of common bile duct stones by percutaneous cholecystostomy also is discussed.     

Interventional radiology of the biliary tract. Intraductal radiation

One palliative method of treating patients with a high duct cholangiocarcinoma is the use of 192Ir wire. This is placed through the tumor, which has been previously intubated, and delivers a high local dose of radiation. The mean survival time in 30 patients treated with intraductal radiation was 16.8 months, an improvement compared to surgical bypass or endoscopic and radiologic drainage procedures.     

Interventional radiology of the biliary tract. Metallic stents

Biliary metallic stents were placed in 18 patients with bile duct obstruction. Six patients received Gianturco stents and 14 Wall-stents. Results of these tests are discussed.     

Interventional radiology in the treatment of early postoperative biliary complications

Purpose

We sought to evaluate the feasibility and efficacy of percutaneous treatment of early postoperative biliary complications. The primary aims were to evaluate clinical and technical success and complications and perioperative mortality, and secondary aims were to evaluate treatment duration and recurrence rate.

Materials and methods

Between March 2007 and March 2010, 75 patients (42 men and 33 women; age range, 17–88 years; mean age, 60.8 years) underwent interventional radiology procedures to treat early postoperative biliary complications of biliary and pancreatic-duodenal surgery with biliodigestive anastomosis (37.7%), laparoscopic cholecystectomy (30.6%), hepatic resection (21.1%) and several other surgical procedures (10.6%). Complications included fistulas (73%), stenoses (20%) and complete bile duct transections (7%).

Results

Interventional radiology achieved complete clinical success in 74 cases (85.9%) and in particular in 95.2% of fistulas, 76.5% of stenoses and 33.3% of complete bile duct transections. Mean indwelling catheter time was 34.9 days, with an average of 4.1 procedures. There were two cases of severe haemobilia (2.3%). Minor complications occurred in 7% of cases. Perioperative mortality rate was 1.2% and overall recurrence rate 6.7% (range, 1–18 months; mean, 10 months), with recurrences occurring predominantly in stenoses. All patients were retreated successfully.

Conclusions

Percutaneous procedures are feasible, effective and safe for treating early postoperative biliary complications. They provide a valuable alternative to presendoscopy, which is precluded in many of these patients, and to surgery, which has higher morbidity and mortality rates.     

Interventional radiology in billiary diseases: A non-surgical therapeutic option

Purpose

This study was undertaken to report our experience in Al-Amiri Hospital in Kuwait in the different billiary interventional procedures used for management of billiary diseases.

Patients and methods

The study was conducted from March 2007 until September 2009 on 64 patients suffering from obstructive jaundice and/or billiary diseases due to different causes.

Results

According to the patient’s diagnosis and the interventional procedure applied, our patients were classified into four groups: (I) patients with malignant obstructive jaundice who had decompression of the obstructed billiary tree; encountered in 44 patients (68.75%). (II) Patients with benign billiary strictures encountered in 9 patients (14.06%), where successful balloon dilatation was encountered in 6 patients (9.37%). (III) Patients with bile duct stones who had stone removal; encountered in 8 patients (12.5%), with successful stones elimination in all of the 8 patients. (IV) Patients with bile leak due to bile duct defect and leakage who had billiary stenting till sealing of the bile leak; encountered in 3 patients (4.68%). Technical and clinical success rate in this patient series was high and comparable with the results of the others.

Conclusion

Percutaneous transhepatic billiary interventional techniques could be done as an alternative management to surgical interference in patients with billiary diseases, with low morbidity and mortality rates and favorable outcome (high clinical success rates).     

恶性梗阻性黄疸介入治疗常见问题的处理

介入治疗作为恶性梗阻性黄疸的重要的治疗手段已经广泛应用,但仍有许多问题值得我们重视和研究。我们总结12年来800余例恶性梗阻性黄疸介入治疗病例的经验;详细分析恶性梗阻性黄疸介入治疗的适应证、禁忌证;研究介入治疗多种并发症的发生原因和处理方法;详细讨论胆管引流方法和胆管支架植入的时机和适应证;提出手术麻醉方法的选择、抗生素和止血药物的应用等见解;总结止痛剂的术前术后临床应用;对术后胰腺炎的发生和处理方法以及围手术期病死率进行了深入的探讨。希望我们的经验和教训能够对介入工作者有所帮助。     

Parasitic diseases of the biliary tract

OBJECTIVE: Parasites residing in the biliary tree include Clonorchis sinensis, Opisthorchis viverrini, Opisthorchis felineus, and Fasciola hepatica. They are willowy, leaf-like, flat flukes dwelling in the bile ducts and gallbladder. Human ascarides, Ascaris lumbricoides, dwelling in the small intestine, inadvertently migrate into the bile ducts and cause biliary obstruction. The purpose of this article is to illustrate typical imaging findings of liver fluke infection and biliary ascariasis. CONCLUSION: Adult flukes of Clonorchis and Opisthorchis measure 8-15 mm and adult flukes of Fasciola measure 20-40 mm in length. The presence of flukes in the bile ducts causes dilatation of the bile ducts, varying degrees of chronic inflammation followed by adenomatous hyperplasia, and bile duct wall thickening. Imaging findings of clonorchiasis and opisthorchiasis include visualization of adult flukes in the bile ducts and gallbladder, diffuse dilatation of the peripheral small intrahepatic bile ducts with no or minimal dilatation of the large bile ducts, and thickening of the bile duct wall. In biliary fascioliasis and ascariasis, adult worms are visualized in the dilated bile ducts and gallbladder.     

Interventional radiology of trauma.

Percutaneous transcatheter embolization has become an integral part of the trauma team's armamentarium. Still, it is probably underused in many centers because of lack of familiarity on the part of both the trauma team and the radiologists. Recognition of the role of interventional radiology in vascular trauma can have a significant impact in decreasing the morbidity and mortality associated with this ever-growing problem in our society.     

急性消化道大出血的介入治疗(附25例报告)

目的探讨急性消化道大出血血管造影的诊断与治疗价值。方法对介入治疗急性消化道大出血25例临床资料进行回顾性分析。结果采用Seldinger技术和同轴导管方法,使导管头端超选择至出血部位,用PVA、明胶海绵或弹簧圈栓塞治疗。25例均能确定出血部位且栓塞成功,达到止血目的,治愈率达100%。结论介入方法不仅可确定出血部位,而且可达到止血目的。此法简单,效果确切,明显优于剖腹探查手术。     

Interventional radiology in the spleen

Despite the widespread use of interventional radiologic techniques, there has been reluctance to apply these to the spleen. Concern for bleeding and difficulty in negotiating around the colon and pleura have limited its use. The authors report their experience with interventional radiology of the spleen in 35 cases, including percutaneous biopsy (n = 5), diagnostic and therapeutic fluid aspiration (n = 14), and catheter drainage of abscesses (n = 9), hematomas (n = 2), intrasplenic pancreatic pseudocysts (n = 2), and necrotic tumor (n = 1). Transsplenic fluid aspiration and biopsy of the pancreas and adrenal gland were performed as well (n = 2). All procedures were performed under computed tomographic or ultrasound guidance. Biopsies were performed with 22- or 20-gauge needles only; no complications were encountered. Diagnoses included primary and secondary malignancies and an infectious process. Drainages were successful in 11 of 14 patients; pleural effusions occurred in two cases, but neither required specific therapy. Interventional radiologic procedures in the spleen are feasible, and the authors discuss methods to promote their safe application.     

Interventional radiology in the treatment of high-flow renal arteriovenous fistulas. Report of two cases

PURPOSE: To describe the morphological and haemodynamic characteristics of high-flow idiopathic renal arteriovenous fistulas and the radiological treatment techniques. MATERIALS AND METHODS: Two cases of idiopathic renal arteriovenous fistula were treated with transcatheter embolization. In the first case, the anomalous arteriovenous communication was embolized with acrylic glue through the afferent artery while the efferent vein was temporarily occluded with a balloon catheter using the "stop flow" technique. In the second case, the fistula was occluded from the arterial side using Gianturco coils and the "free flow" technique. RESULTS: In both cases post-procedural angiography demonstrated occlusion of the fistula. A color-Doppler US examination 6 months later showed the regularization of flow parameters in the renal artery and vein. Angiographic follow-up showed occlusion of the arteriovenous fistula, regularization of the renal artery calibre and normal renal parenchymal flow. CONCLUSIONS: Embolization is the best treatment for rare, high-flow, renal arteriovenous fistulas. The "stop flow" technique with acrylic glue is fast and economical. The "free flow" technique with coils is more expensive and complex, but just as effective.     

Interventional radiology in the gallbladder

This article is a pictorial review of the current status of interventional radiology of the gallbladder. The indications and technical aspects of various procedures are presented. Specifically discussed are: (1) needle puncture for percutaneous biopsy, withdrawal of bile for culture, or imaging of the biliary tract; (2) catheter insertion for decompression or abscess drainage; and (3) gallstone management via contact dissolution, fragmentation and basketing, or contact lithotripsy. The management of vagal hypotension and bile leak, the major complication of these procedures is also discussed.     

经T管应用介入技术封堵外科术后胆管瘘2例

临床资料 患者1:男,65岁.2009年12月因“腹痛伴黄疸、高热1周”在当地医院拟诊“急性化脓性胆管炎伴胆管结石”予以剖腹探查、胆管切开取石、腹腔引流和留置T管持续胆管冲洗引流等外科治疗,症状和体征缓解.2个月后,再次出现黄疸、发热达39℃,T管引流液由约300 ml/d增多达800 ml/d,色黄,浑浊.拟诊“胆管感染”予以加强抗感染治疗和经T管抗生素冲洗,1周后病情逐渐缓解至正常.3周后再次出现上述病情变化,同法治疗后缓解.2010年4月,患者再次出现腹痛、黄疸、发热症状,转诊来我院就诊.完善术前相关检查后行介入治疗,患者仰卧于DSA检查台,右侧胸腹壁及留置T管区域常规消毒,铺巾,将外置T管部分自洞巾中伸出,先夹闭其远端,再以套管针穿刺T管,送入短导丝,引入4F导管鞘作为后续造影及探查通路.     

The removal of retained biliary tract stones: report of 105 cases

The removal of retained biliary stones by the use of the steerable catheter and wire basket after removal of the T-tube has proven itself to be valuable and safe technique. A success rate of 90% or better can be achieved by a radiologist quite quickly. The reduction in morbidity and absence of mortality makes non-operative removal of stones a very desirable service in any hospital doing a significant amount of biliary surgery.