Percutaneous Transhepatic Biliary Drainage Research Articles

Outcome and Complications of Percutaneous Transhepatic Biliary Drainage: Influence of Liver Entry Site

Objective: To determine the outcome and complications of percutaneous transhepatic biliary drainage (PTBD) performed via right lobe and left lobe duct puncture. Study Design: Cross-sectional study. Place and Duration of Study: Department of Interventional Radiology, Dow Institute of Radiology, Dow University of Health Sciences from July 2020 to March 2021. Methodology: Both adult male and female patients with obstructive jaundice having dilated intrahepatic biliary ducts on ultrasound were included. PTBD was performed under ultrasound guidance. Following intrahepatic biliary duct puncture, a guide wire was inserted followed by placement of 8 Fr or 10 Fr pigtail drainage catheter. Total bilirubin level was measured before and one day after the procedure. Cholangiogram was performed 48 hours after the procedure to check the drain placement and residual dilatation. Results: 130 patients were included with mean age of 55.3 ± 12.3 years. Success rate was same in patients with right and left lobe puncture i.e. 96.9%. The frequency of complication in right lobe puncture was higher (37.5%). Mean procedure time was significantly higher in patients who developed complications (75.92 ± 19.20 minutes) as well as mean exposure time was also significantly higher in patients who developed complications (12.00 ± 6.87 minutes) as compared to patients who did not develop any complication (8.08 ± 3.43 minutes) (p <0.05). Conclusion: It was concluded that the success rate in right and left lobe puncture was equal and complication rate in right lobe puncture was observed to be high as compared to left lobe puncture. Keywords: Biliary drainage, Complications, Effect, Liver

Comparing Outcomes Following Endoscopic Ultrasound-Guided Biliary Drainage Versus Percutaneous Transhepatic Biliary Drainage for Malignant Biliary Obstruction: A Systematic Review and Meta-Analysis.

Background: The aim of this study was to explore the efficacy and safety of endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTCD) in patients with malignant biliary obstruction and failed endoscopic retrograde cholangiopancreatography. Methods: We searched PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov to identify studies reporting outcomes comparing EUS-BD and PTCD. Results: We identified 9 studies involving 469 patients. Technical success was similar for EUS-BD and PTCD (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.17-3.30; P = .71). EUS-BD was associated with higher clinical success versus PTCD (OR, 2.11; 95% CI, 1.15-3.87; P = .02) in all studies. However, there was no significant difference between groups in studies using self-expandable metal stents (OR, 0.36; 95% CI, 0.06-2.00; P = .24). The reported adverse event rate was significantly lower for EUS-BD compared with PTCD (OR, 0.33; 95% CI, 0.22-0.52; P < .00001). Conclusion: The available literature suggests that EUS-BD is associated with fewer adverse events, greater clinical success, and comparable technical success compared with PTCD. According to the shortcomings of our study, more large, high-quality, randomized controlled trials are needed to compare these techniques and confirm our findings.

A Rare Complication of Barium Swallow Test

Question: A 70-year-old man with gastroenteropancreatic neuroendocrine tumor of the duodenum underwent robotic subtotal stomach-preserving pancreatoduodenectomy (PD). During the surgery, retrocolic reconstruction for pancreaticojejunostomy and hepaticojejunostomy, as well as antecolic reconstruction for gastrojejunostomy, were performed. Surgical anatomy following these reconstructions is illustrated in Figure A. The patient’s postoperative follow-up was uneventful. Six months later, the patient underwent a barium swallow test for a medical checkup at another hospital. The examination found no significant findings in the stomach, but revealed reflux of the barium sulfate into the intrahepatic biliary trees through the afferent loop (Figure B). After the barium swallow test on that day, the patient was referred to our hospital. He complained only of fever, but did not demonstrate other symptoms. The laboratory findings showed the following unremarkable changes: white blood cell, 6920/μL; total bilirubin, 0.89 mg/dL; direct bilirubin, 0.25 mg/dL; aspartate transaminase 23 U/L; alanine aminotransferase, 22 U/L; and C-reactive protein, 0.76 mg/dL. The abdominal computed tomography revealed retained barium sulfate in the bilateral biliary system (Figure C). What is the treatment strategy for this patient? Look on page 402 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. Retained barium sulfate in the biliary system may cause hepatolithiasis because of progressive water absorption, leading to complications such as obstructive jaundice, cholangitis, and sepsis.1Walsham A. Larsen J. Adverse effects of barium sulfate in the biliary tract.Diagn Interv Radiol. 2008; 14: 94-96PubMed Google Scholar Despite the absence of guidelines for the treatment of barium-induced choleliths, evidence-based guidelines for hepatolithiasis after biliary reconstruction propose peroral endoscopic treatment as the first-line option, or percutaneous transhepatic biliary drainage (PTBD) as an alternative.2Tazuma S. Unno M. Igarashi Y. et al.Evidence-based clinical practice guidelines for cholelithiasis 2016.J Gastroenterol. 2017; 52: 276-300Crossref PubMed Scopus (71) Google Scholar However, endoscopic approaches using a double-balloon endoscope (DBE) could be less invasive and have several advantages in bilateral drainage as well as in the accurate evaluation for residual choleliths with peroral direct cholangioscopy.3Ishihara Y. Matsumoto K. Kato H. et al.Treatment outcomes, including risk factors of stone recurrence, for hepatolithiasis using balloon-assisted endoscopy in patients with hepaticojejunostomy (with video).Surg Endosc. 2020; 34: 1895-1902Google Scholar Therefore, urgent endoscopic intervention was attempted in this case. In facilities where DBEs are not available, PTBD should be considered. Using DBE, saline was injected into the biliary trees via a catheter through the hepaticojejunostomy, and barium sulfate lodged at the main bile duct was washed out (Figure D). An endoscopic nasobiliary drainage tube was placed, and further irrigation was conducted for 3 days. After confirmation of duct clearance by a computed tomography scan, the patient was discharged. The reflux of orally administered barium sulfate into the intrahepatic biliary system is a rare but complicated adverse effect of a barium swallow test. To date, several conditions, including spontaneous or postoperative fistula and choledochoenterostomy, have been reported to be associated with reflux.1Walsham A. Larsen J. Adverse effects of barium sulfate in the biliary tract.Diagn Interv Radiol. 2008; 14: 94-96PubMed Google Scholar However, to our knowledge, this report is the first of barium sulfate reflux into the intrahepatic biliary trees in a patient undergoing PD. Urgent endoscopic intervention was safe and effective to prevent barium-induced biliary complications. In conclusion, the present case demonstrated a rare complication of barium sulfate in the biliary system following biliary reconstruction. It suggests that barium swallow test following PD should be contraindicated. Therefore, in similar patients experiencing this rare adverse effect, urgent intervention with DBE or PTBD should be performed to avoid complex biliary complications.

Total Fluoroscopy Time Reduction During Ultrasound- and Fluoroscopy-Guided Percutaneous Transhepatic Biliary Drainage Procedure: Importance of Adjusting the Puncture Angle.

BackgroundThe purpose of this observational cohort study was to assess patient and operator-dependent factors which could have an impact on total fluoroscopy time during ultrasound and fluoroscopy-guided percutaneous transhepatic biliary drainage (PTBD).Material/MethodsBetween October 2016 and November 2020, 127 patients with malignant biliary obstruction underwent ultrasound- and fluoroscopy-guided PTBD with the right-sided intercostal approach. The initial bile duct puncture was ultrasound-guided in all patients, and the puncture angle was measured by ultrasound. Any subsequent steps of the procedure were performed under continuous fluoroscopy (15 fps). The patients were divided in 2 groups based on the puncture angle: ≤30° (group I) and >30° (group II). In a retrospective analysis, both groups were compared for inter- and intragroup variability, technical success, total fluoroscopy time, and complications.ResultsIn group II, the recorded total fluoroscopy time (232.20±140.94 s) was significantly longer than that in group I (83.44±52.61 s) (P<0.001). In both groups, total fluoroscopy time was significantly longer in cases with a lesser degree of bile duct dilatation, intrahepatic bile duct tortuosity, presence of liver metastases, and multiple intrahepatic bile duct strictures.ConclusionsThe initial bile duct puncture angle was identified as an operator-dependent factor with the possible impact on total fluoroscopy time. The puncture angle of less than 30° was positively correlated with overall procedure efficacy and total fluoroscopy time reduction.

EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent placement should replace PTBD after ERCP failure in patients with distal tumoral biliary obstruction: a large real-life study.

In cases of malignant distal biliary obstruction, ERCP is the preferred technique for bile duct drainage. In case of failure, the alternative techniques are percutaneous transhepatic biliary drainage (PTBD) and more recently endoscopic ultrasound-guided biliary drainage. A new type of stent called the electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) has been developed to enable the performance of biliary-enteric anastomosis under EUS-guidance in a single step, without prior bile duct puncture or the need for a guidewire. The aim of our study was to compare the real-life efficacies of PTBD and EUS-BD with the EC-LAMS for cases of ERCP failure in patients with malignant biliary obstruction. We performed a monocentric retrospective study comparing PTBD and EUS-BD with the use of electrocautery-enhanced lumen-apposing metal stent in the context of a malignant distal biliary obstruction after ERCP failure. 95 patients were included (50 in EUS-BD group and 45 in PTBD group). The main etiology of malignant obstruction was adenocarcinoma of the head of pancreas (85%). There was a significant difference in favor of endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced lumen-apposing metal stent for the following criteria: clinical success: 89.3% vs. 45.5%; p < 0.0001; procedure-related adverse event rate: 2.12% vs. 22.7%; p = 0.003; duration of post-drainage hospitalization: 3.5 vs. 8.2days; p < 0.0001, overall survival (median survival): 118.2 vs. 42days; p = 0.012, overall cost of the strategy per patient: 5098 vs. 9363 euros; p < 0.001. Our results are in favor of EUS-BD using electrocautery-enhanced lumen-apposing metal stent in case of ERCP failure for a distal tumor biliary obstruction. Operators performing ERCP for distal tumor biliary obstruction must learn this backup procedure because of its superiority over percutaneous transhepatic biliary drainage in terms of clinical success, safety, cost, and overall survival.

S2519 Recurrent Haemobilia Due to Hepatic Artery Pseudoaneurysm Secondary to Percutaneous Transhepatic Biliary Drainage and Biliary Stent Placement

S2519 Recurrent Haemobilia Due to Hepatic Artery Pseudoaneurysm Secondary to Percutaneous Transhepatic Biliary Drainage and Biliary Stent Placement

Outcomes of percutaneous biliary stent placement for malignant hilar biliary obstruction

Abstract Introduction: This study aims to evaluate the effectiveness and safety of the percutaneous biliary stent placement for malignant hilar biliary obstruction (MHBO). Patients and Method: Percutaneous biliary stent was placed in 50 patients with MHBO at Viet Duc University Hospital from June 2019 to July 2020. The patients were monitored during their hospitalization, at 1-month and long-term follow-up on clinical symptoms and laboratory results as well as complications. The effect and safety of this technique were evaluated. Results: Successful rate was 98%. The total serum bilirubin decreased from 280.06 ± 164.65 µmol/L before to 165.09±112.90 µmol/L one week later (p&lt;0.001). Additionally, the AST and ALT significantly decreased (p&lt;0.001). Early complication rate was 22.4%, and late complication rate was 2.0% respectively. The stent occlusion rate was 20.4%. The median survival time was 144.2 days. Conclusion: The percutaneous biliary stent placement is a safe and effective palliative therapy for MHBO, helps to improve liver function and quality of life of patients. Keywords: Biliary stent, hilar biliary obstruction, percutaneous trans-hepatic biliary stent, percutaneous trans-hepatic biliary drainage.

Diagnostic and therapeutic management algorithm for biliary complications in living liver donors.

This study aimed to demonstrate the efficacy of our diagnostic and therapeutic management algorithm and catheter-assisted (percutaneous transhepatic biliary tract drainage [PTBD] or transanastomotic feeding tube) hepaticojejunostomy (HJ) procedures in living liver donors (LLDs) with biliary complications. Living donor hepatectomy (LDH) was performed between September 2005 and April 2021 in 2 489 LLDs. Biliary complications developed in 220 LLDs (8.8%), 136 of which were male, and the median age was 29 (interquartile range [IQR]: 12) years. Endoscopic sphincterotomy ± stenting was performed in 132 LLDs, which was unsuccessful in 9 LLDs and required HJ. Overall, 142 LLDs underwent interventional radiologic procedures. Fifteen LLDs with biliary complications underwent HJ (PTBD catheter = 6 and transanastomotic feeding tube = 9) at a median of 44 days (IQR: 82). Following HJ, 14 LLDs did not have any complications throughout the median follow-up period of 1619 days (IQR: 1454). However, percutaneous dilation for HJ anastomotic stricture was performed in one patient. Biliary complications are very common following LDH; therefore, surgeons in the field should have a low threshold to perform HJ for biliary complications that persist after other treatments. Our catheter-assisted HJ techniques demonstrated a high success rate and aided HJ in a hostile abdomen during revisional surgery.

Successful transpapillary removal of a migrated percutaneous transhepatic biliary drainage tube with a digital peroral cholangioscope

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Outcomes of Endoscopic Ultrasound-Guided Biliary Drainage in a General Hospital for Patients with Endoscopic Retrograde Cholangiopancreatography-Difficult Transpapillary Biliary Drainage.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been developed as an alternative treatment for percutaneous transhepatic biliary drainage for patients with bile duct stenosis. At specialized hospitals, the high success rate and effectiveness of EUS-BD as primary drainage has been reported. However, the procedure is highly technical and difficult, and it has not been generally performed. In this study, we retrospectively examined the effectiveness of EUS-BD in ERCP-difficult patients with distal bile duct stenosis. We retrospectively examined 24 consecutive cases in which EUS-BD was performed at our hospital for distal bile duct stenosis from October 2018 to December 2020. EUS-guided choledochoduodenostomy (EUS-CDS) was selected for cases that could be approached from the duodenal bulb, and EUS-HGS was selected for other cases. In the EUS-CDS and EUS-HGS groups, the technical success rates were 83.3% (10/12] and 91.7% (11/12], respectively. An adverse event occurred in one case in the EUS-CDS group, which developed severe biliary peritonitis. The stent patency period was 91 and 101 days in the EUS-CDS and EUS-HGS groups, respectively. EUS-BD for ERCP-difficult patients with distal bile duct stenosis is considered to be an effective alternative for biliary drainage that can be performed not only in specialized hospitals but also in general hospitals.

Role of Percutaneous Transhepatic Biliary Drainage as an Adjunct to Endoscopic Retrograde Cholangiopancreatography

There is limited literature on the role of percutaneous transhepatic biliary drainage (PTBD) as an adjunct to endoscopic retrograde cholangiopancreatography (ERCP). This study evaluates the role of PTBD in patients with failed ERCP or post-ERCP cholangitis. Retrospective evaluation of clinical and intervention records of patients with biliary obstruction referred for PTBD following failed ERCP or post-ERCP cholangitis was performed. The cause of biliary obstruction, baseline serum bilirubin, white blood cell (WBC) count, serum creatinine, and procalcitonin were recorded. Technical success and clinical success (resolution of cholangitis, reduction in bilirubin levels, WBC count, creatinine, and procalcitonin) were assessed. Sixty-three patients (35 females, mean age 51.4 years) were included. Indications for ERCP included malignant causes in 47 (74.6%) cases and benign causes in 16 (25.4%) cases. Indications for PTBD were failed ERCP in 21 (33.3%) and post-ERCP cholangitis in 42 (66.7%). PTBD was technically successful in all patients. Clinical success rate was 68.2% in the overall group. Mild hemobilia was noted in five (7.9%) patients. There were no major complications or PTBD related mortality. Cholangitis and acute kidney injury resolved following PTBD in 63.1% and 80% of the patients, respectively. Total serum bilirubin reduced by 47.8% and 69.4% after one week and one month of the PTBD, respectively. The average fall in procalcitonin was 5.17ng/mL after one week of the PTBD. PTBD is an important adjunctive drainage procedure in patients with ERCP failure or post-ERCP cholangitis.

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.

Institutional Diagnostic Reference Levels and Peak Skin Doses in selected diagnostic and therapeutic interventional radiology procedures.

Institutional (local) Diagnostic Reference Levels for Cerebral Angiography (CA), Percutaneous Transhepatic Cholangiography (PTC), Transarterial Chemoembolization (TACE) and Percutaneous Transhepatic Biliary Drainage (PTBD) are reported in this study. Data for air kerma-area product (PKA), air kerma at the patient entrance reference point (Ka,r), fluoroscopy time (FT) and number of images (NI) as well as estimates of Peak Skin Dose (PSD) were collected for 142 patients. Therapeutic procedure complexity was also evaluated, in an attempt to incorporate it into the DRL analysis. Local PKA DRL values were 70, 34, 189 and 54Gy.cm2 for CA, PTC, TACE and PTBD respectively. The corresponding DRL values for Ka,r were 494, 194, 1186 and 400mGy, for FT they were 9.2, 14.2, 27.5 and 22.9min, for the NI they were 844, 32, 602 and 13 and for PSD they were 254, 256, 1598 and 540mGy respectively. PKA for medium complexity PTBD procedures was 2.5 times higher than for simple procedures. For TACE, the corresponding ratio was 1.6. PSD was estimated to be roughly 50% of recorded Ka,r for procedures in the head/neck region and 10% higher than recorded Ka,r for procedures in the body region. In only 5 cases the 2Gy dose alarm threshold for skin deterministic effects was exceeded. Procedure complexity can differentiate DRLs in Interventional Radiology procedures. PSD could be deduced with reasonable accuracy from values of Ka,r that are reported in every angiography system.

Cholangiojejunostomy assisted by techniques of interventional radiology for a patient with recurrent jaundice after Kasai portoenterostomy

A 10-month-old girl who had previously undergone Kasai portoenterostomy (KP) for biliary atresia was admitted because of recurrent jaundice. Intrahepatic bile duct (IHBD) dilation was observed in the lateral segment close to the umbilical portion of the portal vein on ultrasonography and computed tomography. Although percutaneous transhepatic biliary drainage by a radiologist alleviated jaundice, internal fistula formation, which was subsequently attempted, was unsuccessful due to the narrow and complicated IHBD morphology. Therefore, side-to-side cholangiojejunostomy between the dilated IHBD and jejunum of the Roux-en-Y limb was performed using intraoperative interventional radiology techniques. The patient's postoperative course was uneventful. In patients with recurrent jaundice after KP, especially that associated with solitary IHBD dilatation, a high success rate of achieving good bile flow can be expected using current techniques.

Management of extra hepatic biliary obstruction, in a rural tertiary care hospital India

Background: Extra hepatic biliary obstruction (EHBO) is not a rare surgical problem; our experience in managing 36 patients over a period of two years at a tertiary care hospital in a rural setting in India. The objective was to study the etiology and clinical presentation of patients with EHBO, role of various investigative modalities and management strategies in these patients and their outcome.Methods: This was a prospective study conducted between September 2018 to August 2020 in the department of surgery in tertiary care center Subharti medical college (SMC) Meerut. Data was taken in a pre-formed performa and the results were tabulated and analyzed (descriptive analysis).Results: Out of 36 patients, 2 (5.5%) patients underwent choledochoduodenostomy, 1 (2.7%) exploratory laparotomy with CBD exploration with t tube drainage, 1 (2.7%) ERCP with pigtail drainage; 17(47.2%) ERCP (endoscopic retrograde cholangiopancreatography) followed by cholecystectomy, 1 (2.7%) open cholecystectomy with t tube drainage, 4 (11.1%) ERCP alone, 2 (5.5%) hepaticojejunostomy, 1 (2.7%) ERCP followed by diverticulectomy, 2 (5.5%) PTBD (percutaneous transhepatic biliary drainage) followed by a triple bypass surgery, 2 (5.5%) PTBD, 1 (2.7%) pylorus preserving pancreaticoduodenectomy, 1 (2.7%) ERCP with sphincterotomy, 1 (2.7%) PTBD followed by whipples procedure. Patients were followed up and 5 (13.8%) patients had recurrence of the disease.Conclusions: EHBO is a hepatobiliary surgical condition caused by both neoplastic and non-neoplastic etiology. Benign pathologies common in younger patients whereas neoplastic conditions in older age. Ultrasonography is the most common investigative modality followed by ERCP with PTBD/ENBD playing an important role in decompression of biliary obstruction as a palliative measure in advanced malignancies.

Complications of percutaneous transhepatic cholangiography and biliary drainage, a multicenter observational study

ObjectivesOver 2500 percutaneous transhepatic cholangiography and biliary drainage (PTCD) procedures are yearly performed in the Netherlands. Most interventions are performed for treatment of biliary obstruction following unsuccessful endoscopic biliary cannulation. Our aim was to evaluate complication rates and risk factors for complications in PTCD patients after failed ERCP.MethodsWe performed an observational study collecting data from a cohort that was subjected to PTCD during a 5-year period in one academic and four teaching hospitals. Primary objective was the development of infectious (sepsis, cholangitis, abscess, or cholecystitis) and non-infectious complications (bile leakage, severe hemorrhage, etc.) and mortality within 30 days of the procedure. Subsequently, risk factors for complications and mortality were analyzed with a multilevel logistic regression analysis.ResultsA total of 331 patients underwent PTCD of whom 205 (61.9%) developed PTCD-related complications. Of the 224 patients without a pre-existent infection, 91 (40.6%) developed infectious complications, i.e., cholangitis in 26.3%, sepsis in 24.6%, abscess formation in 2.7%, and cholecystitis in 1.3%. Non-infectious complications developed in 114 of 331 patients (34.4%). 30-day mortality was 17.2% (N = 57). Risk factors for infectious complications included internal drainage and drain obstruction, while multiple re-interventions were a risk factor for non-infectious complications.ConclusionBoth infectious and non-infectious complications are frequent after PTCD, most often due to biliary drain obstruction.

An Evidence-Based Approach to Nursing Recognition and Management of Early Sepsis in Percutaneous Transhepatic Biliary Drainage (PTBD)

<h3>Introduction</h3> Percutaneous Transhepatic Biliary Drainage (PTBD) is an interventional radiology (IR) procedure indicated for relief of biliary obstructive symptoms: pruritus, jaundice ang cholangitis cause by benign or malignant conditions. Gallstones, cholangiocarcinoma and hepatobiliary malignancy are frequently seen to cause sepsis. <h3>Identification of the Problem</h3> Although PTBD is generally a safe procedure, significant complications manifest as systemic inflammatory response syndrome (SIRS) that leads to mortality. Early post anesthesia care unit (PACU) nursing recognition is critical in effectively managing these high risk patients. <h3>EBP Question/Purpose: PICO question. Databases utilized</h3> What is the best practice for patients post biliary drain placement presenting symptoms of systemic inflammatory response syndrome (SIRS)? (P) Patients post PTBD; (I) Early recognition of SIRS; (C) Prompt/early management of SIRS compare to standard care in alleviating sepsis (O). The evidence-based practice (EBP) searches were conducted using PUBMED/CINAHL databases. <h3>Methods/Evidence</h3> The evidence reviewed from PUBMED/CINAHL ranged from 2013 to 2019. Mesh terms were: interventional, biliary drainage, PTBD, pathophysiology, cholangitis, symptoms, complications, sepsis and SIRS. The first search yielded eight out of 36 articles that met PICO criteria. The second and final search included eight additional articles with terms of mortality and patient outcomes. <h3>Significance of Findings/Outcomes</h3> EBP appraisal revealed compelling science for recognizing and managing early SIRS in PTBD patients. Team created an EBP algorithm (see poster) that was effective for PACU nurses in early recognition of SIRS and prompt PACU nursing management to mitigate deteriorating symptoms of increased heart rates and rigors followed by fevers to improve quality patient care. <h3>Implications for perianesthesia nurses and future research</h3> Post PTBD SIRS can be challenging for PACU nurses to manage life-threatening complications. Evidence supports the development of an algorithm tool that focuses on recognition, assessment, and appropriate management of SIRS in this population. The science recommends easy accessibility of standing physician order sets, including medications, such as intravenous (IV) fluids, IV antibiotics, and acetaminophen as SIRS management in PACU strategies to facilitate positive patient outcomes.

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.

CIRSE Standards of Practice onPercutaneous Transhepatic Cholangiography, Biliary Drainage and Stenting.

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

Management of biliary diseases after the failure of initial needle knife precut sphincterotomy for biliary cannulation

Endoscopic retrograde cholangiopancreatography is not always successful even with needle knife precut sphincterotomy (NKPS). How to manage these patients with initial NKPS failure has not been well studied. We report the outcomes of patients who received endoscopic and non-endoscopic rescue treatment after the initial NKPS failure. During the 15 years from 2004 to 2018, 87 patients with initial NKPS failure received interval endoscopic treatment (IET group, n = 43), percutaneous transhepatic biliary drainage (PTBD group, n = 25), or bile duct surgery (BDS group, n = 19) were retrospectively studied. Compared with the PTBD group, the prevalence of choledocholithiasis was higher (69.8% vs. 16.0%, p < 0.001), and malignant bile duct stricture were lower (20.9% vs. 76.0%, p < 0.001) in the IET group. Furthermore, the IET group had a significantly longer time interval between the first and second treatment procedures (4 days vs. 2 days, p = 0.001), a lower technique success rate (79.1% vs. 100%, p = 0.021), and a shorter length of hospital stay (7 days vs. 18 days, p < 0.001). Compared to the BDS group, the only significant finding was that the patients in the IET group were older. Although not statistically significant, the complication rate was lowest in the IET group (7.0%) while highest in the BDS group (15.8%). Complications in the IET group were also mild, as compared with the other two groups. In conclusion, IET should be considered after initial failed NKPS for deep biliary cannulation before contemplating more invasive treatment such as BDS. PTBD may be the alternative therapy for patients with malignant biliary obstruction.