Nondilated Intrahepatic Ducts Research Articles

Transcholecystic management of extrahepatic duct stones in poor candidates for endoscopic or transhepatic approaches.

To investigate transcholecystic management of extrahepatic duct (EHD) stones using balloon ampulloplasty in patients who are poor candidates for endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) and assess its efficacy and safety. Forty-one patients who were unable to undergo ERCP or had failed ERCP with non-dilated intrahepatic ducts (IHD) between February 2019 and October 2020 were retrospectively enrolled. After clinical improvement with percutaneous cholecystostomy (PC), EHD stones were managed through cystic duct passage, guidewire unwinding, sheath insertion, and EHD stone removal using balloon ampulloplasty. If the transcholecystic route failed, a transhepatic approach was used according to the pre-existing cholangiogram obtained via PC. We evaluated the technical success rate and complications of each step. The technical success rate for the transcholecystic-only approach was 80.5%. The remaining cases were successfully managed with transhepatic conversion. Multiple stone removal sessions were required in 22% of the cases. One patient with combined IHD stones was initially converted to a transhepatic approach without any transcholecystic removal trial. The technical success rates for each step were as follows: cystic duct passage (38/40, 95%), guidewire unwinding (36/38, 94.7%), sheath insertion (36/36, 100%), and stone removal using balloon ampulloplasty (33/36, 91.7%). The overall clinical success was 97.6% (40/41) without major procedure-related complications. Thereafter, cholecystectomy was successfully performed in patients with concomitant gallstones (n = 20). No postprocedural complications occurred during the follow-up (1-70days). Percutaneous EHD stone removal through transcholecystic and transhepatic routes after PC is effective and safe in poor candidates for PTBD or ERCP. • This study shows the safety and efficacy of extrahepatic duct (EHD) stones in patients who are poor candidates for initial percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiopancreatography. • The overall technical success for the transcholecystic-only approach was 80.5% (33/41). Including transhepatic conversions, it was 100% (41/41). Stone removal was successful in one session in 78% (32/41) of the patients and in multiple sessions in 28.1% (9/41) of the patients. • Balloon ampulloplasty with stone expulsion using an occlusion balloon catheter is also a safe and effective method for removing EHD stones.

Clinical Risk Factors for Complications in Patients Undergoing Percutaneous Transhepatic Cholangioscopy

Background/Aim: Percutaneous transhepatic cholangioscopy (PTCS) has been widely used for the diagnosis and treatment. PTCS-related complications (hemobilia, cholangitis, biliary tract perforations) are not infrequent. However, data on the risk factors for PTCS-related complications are limited. Therefore, we aimed to identify the risk factors for PTCS-related complications.Methods: Two hundred thirty-three patients who underwent PTCS at a single tertiary center between January 2006 and October 2014 were enrolled. After retrospectively analyzing the patients’ medical records, 212 patients were enrolled and classified into two groups: 1) a complication group and 2) a non-complication group.Results: The study population comprised 112 men and 100 women, with a median age of 64.5 years. Of the 212 patients, 32 (15.1%) developed complications: 14 (6.7%) developed cholangitis, six (2.8%) developed bile duct injury, and two (0.9%) developed hemobilia. In the univariate analyses, older age, a small number of tract dilatation sessions, and computed tomography (CT) findings of liver cirrhosis and a non-dilated intrahepatic duct were risk factors for PTCS-related complications. In the multivariate analysis, older age, a small number of tract dilatation sessions, and the CT finding of a non-dilated intrahepatic duct were independent factors for predicting PTCS-related complications. Serial tract dilatations (≥2 sessions) were performed in 95 patients (44.8%), but this did not affect the complication rate. In this subgroup of patients, a short interval between sessions (≤3 days) was associated with PTCSrelated complications.Conclusions: Elderly patients and those with non-dilated intrahepatic ducts on CT need to be managed carefully. Stepwise tract dilatations and a long interval between sessions (>3 days) can help decrease PTCS-related complications.

Ketamine-related cholangiopathy: a retrospective study on clinical and imaging findings.

Ketamine is a commonly abused recreational drug in Southeast Asia. There are emerging reports on ketamine abuse causing liver injury and biliary dilatation. This retrospective study aims to investigate the clinical and radiological features of this condition. A retrospective search in the database of our institute was performed from January 2008 to February 2014 for patients who were ketamine abusers, with deranged liver function and/or epigastric pain, and had computed tomography of the abdomen or magnetic resonance cholangiopancreatography. Patient demographics, clinical data, and radiological findings were reviewed. Twenty-six patients (11 male and 15 female) were included in this study. Eighteen (69%) patients had fusiform dilatation of the common bile ducts (CBDs) without evidence of intrinsic or extrinsic obstruction, and non-dilated intrahepatic ducts. The degree of CBD dilatation correlated with duration of abuse. In five patients who achieved abstinence, the CBD dilatation showed improvement. Ketamine-related cholangiopathy manifested as fusiform dilatation of the CBD without evidence of obstructive lesions. Severity of CBD dilatation appears to be correlated with the duration of ketamine, and the condition is potentially reversible in abstinent patients.

Visualization of the Biliary Tract Using Gadobenate Dimeglumine

To compare contrast-enhanced magnetic resonance (MR) cholangiography (CE-MRC) performed with gadobenate dimeglumine with T2-weighted MRC (T2-MRC) for visualization of the bile ducts in nondilated biliary systems. Twenty consecutive patients who underwent MR imaging (MRI) of the liver and pancreas with nondilated intrahepatic ducts were included in this retrospective study. T2-weighted MRC was performed using a multislice, high-resolution fat-suppressed half-Fourier acquisition turbo spin-echo sequence. Contrast-enhanced MR cholangiography was performed using a fat-suppressed 3-dimensional fast low-angle shot sequence acquired 1 to 1.5 hour after intravenous administration of gadobenate dimeglumine. For image interpretation, the biliary system was divided into 8 segments. Two readers graded visualization of each segment on T2-MRC and CE-MRC using a 5-point scale (0, nonvisualization; 4, excellent visualization). Final opinion for each sequence was rendered by consensus. Superiority of visualization was assessed using the McNemar test and comparing adequately (visualization scores 3 and 4) and inadequately (visualization scores 0, 1, and 2) visualized segments of the ducts on both sequences. Interobserver variability was assessed with kappa statistics. Overall and segment-based evaluation revealed superior visualization of biliary segments with CE-MRC compared with T2-MRC. We also found a statistically significant difference between the 2 sequences for overall and for right hepatic duct and cystic channel visualization (P < 0.05). A high concordance between readers 1 and 2 both for T2-MRC and CE-MRC was achieved (85.8% and 89.4%, respectively). Gadobenate dimeglumine can be used as an alternative intrabiliary contrast agent for contrast-enhanced MR cholangiography in nondilated biliary systems in patients with normal excretory liver function tests.

Spontaneous Fracture of a Biliary Self-Expanding Metal Stent

The endoscopic placement of a self-expanding metallic stent (SEMS) is an established treatment for inoperable malignant biliary obstruction, providing relatively prolonged palliation with acceptably low failure and complication rates [1]. Complications related to SEMSs include entrapment of the stent delivery system in small or nondilated intrahepatic ducts, malpositioning of the stent, stent occlusion due to tumor ingrowth or biliary epithelial hyperplasia, proximal or distal migration, and trauma to the duodenal wall opposite the papilla, resulting in bleeding or perforation. Although SEMS are generally not removable, successful endoscopic retrieval of such stents for the treatment of late complications has been reported. Fracture of a SEMS is a rare complication and has only occasionally been reported in the biliary system, caused by thermal overstrain during the application of laser or electrocautery [2] [3] [4] [5].

Percutaneous transhepatic cholangiography and biliary drainage in pediatric liver transplant patients.

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. 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. 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). 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.

Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts.

We evaluated the technical success and complications of percutaneous transhepatic biliary drainage in patients with nondilated intrahepatic bile ducts. Between January 1, 1996, and August 31, 1998, 130 percutaneous transhepatic biliary drainage procedures were performed on patients with nondilated intrahepatic bile ducts. This group comprised primarily patients who had received liver transplants or who had sustained iatrogenic bile duct injuries. Access in all procedures was performed using a one-step system consisting of a 21-gauge needle and an .018-inch guidewire. The technical success and complications of the procedures were evaluated. Percutaneous biliary drainage was successful in 117 (90%) of 130 attempts. In four patients, two attempts were required to place a drainage catheter. The overall complication rate was 9%. There were seven (5%) minor complications and five major complications (4%). No procedure-related deaths occurred. Percutaneous biliary drainage can be performed with a high success rate in patients with nondilated intrahepatic ducts. The incidence and types of complications in this population were similar to those reported in patients with intrahepatic ductal dilatation.

THE MANAGEMENT OF T TUBE LEAKS IN ORTHOTOPIC LIVER TRANSPLANT RECIPIENTS WITH ENDOSCOPICALLY PLACED NASOBILIARY CATHETERS

Biliary tract problems remain an important cause of complication following orthotopic hepatic transplantation. We describe 12 liver transplantation patients who developed bile peritonitis secondary to a biliary leak after T tube removal. Each of these patients underwent an urgent ERCP that exhibited leakage outside the T tube tract and nondilated intrahepatic ducts. At the time of the ERCP, a nasobiliary catheter was inserted to divert the bile flow. All of these patients resolved their symptoms and closed their leak. We advocate endoscopic placement of a nasobiliary catheter as first-line therapy for significant T tube tract leaks after liver transplantation.