Percutaneous Transhepatic Biliary Drainage Procedures Research Articles

The Complication of Hepatic Artery Injuries of 1,304 Percutaneous Transhepatic Biliary Drainage in a Single Institute

PurposeTo determine frequency of and assess risk factors for hepatic artery (HA) injury during percutaneous transhepatic biliary drainage (PTBD) and to discuss the technique and report the clinical outcome of embolization for HA injury. Materials and MethodsOver a 14-year period (2002–2016), 1,304 PTBD procedures in 920 patients were recorded. The incidence of HA injury was determined, and possible associated risk factors were analyzed. When injury occurred, HA embolization was performed at the site as close to the bleeding point as possible. Clinical outcomes of these patients after embolization were reported. ResultsOf 1,304 PTBD procedures, a left-sided approach was used in 722 procedures (55.4%), and intrahepatic duct (IHD) puncture under ultrasound guidance was used in 1,161 procedures (90.1%). The IHD was nondilated in 124 (9.5%) patients. The punctured ductal entry site was peripheral in 1,181 (90.6%) patients. In this series, 8 procedures (0.61%) were complicated by HA injury. IHD dilatation status was the only risk factor (P = .017) for HA injury. Embolization was performed with technical and clinical success in all 8 patients. No recurrent hemobilia, intraabdominal bleeding, or other sequelae of HA injury after embolization was noted during 1 week to 84 months of follow-up. ConclusionsHA injury is a relatively rare complication of PTBD. IHD dilatation status was the only risk factor for HA injury in this study. When HA injury occurred, embolization therapy was effective in managing this complication.

Acute Pancreatitis After Percutaneous Biliary Drainage: An Obstacle in Liver Surgery for Proximal Biliary Cancer.

Percutaneous transhepatic biliary drainage (PTBD) has a crucial role in treatment of proximal biliary cancer (PBC). We assessed the incidence, risk factors, and impact of acute pancreatitis (AP) post-PTBD. Forty patients with PBC scheduled for PTBD from January 2005 to December 2015 were enrolled. Exclusion criteria were missing clinical data, PTBD performed in other institutions, and palliative PTBD. The 40 patients comprised 8 (20%) with gallbladder cancer, 6 (15%) with intrahepatic cholangiocarcinoma, and 26 (65%) with perihilar cholangiocarcinoma. A median of 1 PTBD procedure was performed per patient; 16 (40%) patients underwent PTBD more than once. PTBD was left-sided in 14 (35.0%) patients, right-sided in 21 (52.5%), and bilobar in 5(12.5%). Seventeen (42.5%) patients had one or more drainage-related complications. Five (12.5%) patients developed AP. A significantly higher percentage of patients with than without AP developed sepsis (60.0 vs. 11.4%, respectively) and did not undergo the planned liver resection [2 (40.0%) vs. 0 (0.0%), respectively]. Significantly more patients with than without AP underwent left-sided PTBD [10 (28.6%) vs. 4 (80.0%), respectively]. PTBD is frequently complicated by AP. AP plays a key role in the development of sepsis. Nearly half of patients with AP lose the opportunity for surgical treatment.

Sonographic-Guided Percutaneous Transhepatic Biliary Drainage aia Peripheral Access: Evaluation of Safety and Technical Efficacy

Biliary drainage is an important technique for decompression in biliary obstruction, regardless of what causes of obstruction. Percutaneous transhepatic biliary drainage is the first choice for the interventional radiological procedure for treatment of obstructive jaundice. The purpose of this study was to evaluate the safety and efficacy of percutaneous transhepatic biliary drainage via peripheral access under sonographic guidance for treatment of obstructive jaundice. We retrospectively reviewed 61 percutaneous transhepatic biliary drainage procedures in 58 patients with obstructive jaundice over a 2 year period. All patients underwent percutaneous transhepatic biliary drainage under sonographic guidance. The efficacy of this technique was defined as inserted drainage tube enabling adequate bile drainage and decreased the value of bilirubin. Fifty seven patients (98.3%) had successful percutaneous transhepatic biliary drainage under sonographic guidance via peripheral access. Percutaneous transhepatic biliary drainage procedure was successfully achieved in 45 (97.8%) procedures via right lobe liver approach and 15 (100%) procedures via left lobe liver approach. The mean number of puncture per patient was 3.50 (range, 1–10). The value of total bilirubin of all patients was decreased within three days after procedure. There were four minor complications (6.6%, 4/61) without further treatment. Percutaneous transhepatic biliary drainage via peripheral access under sonographic guidance is a safe and effective treatment of patients with obstructive jaundice.

A National Survey on Peri-interventional Management of Percutaneous Transhepatic Biliary Drainage.

The purpose of this study is to evaluate knowledge about management of percutaneous transhepatic biliary drainage (PTBD) catheters among nurses taking care of hepato-pancreato-biliary (HPB) patients. Six HPB nurses from the Dutch national HPB association created a questionnaire that was complemented by 2 HPB surgeons, 3 HPB interventional radiologists, and a methodologist. Registered nurses working at the department of gastroenterology or gastrointestinal surgery and familiar with the care for HPB patients were invited to complete the questionnaire. In total 120 completed questionnaires from Dutch nurses were returned. The responders were working in 38 of 64 different hospitals. About half of the respondents considered their own knowledge insufficient, which was reflected in the response to the specific questions concerning the PTBD procedure, and 70% rated the knowledge of their immediate nursing colleagues as insufficient. Less than 50% of the respondents knew whether antibiotic-prophylaxis or "pain medication" was required before PTBD procedure. Only a few respondents were aware of the existence of a hospital protocol for PTBD management and its content. Nursing care for biliary catheters is not standardized nationwide, and consensus on management is lacking. An evidence-based guideline for PTBD management is advised for nursing care of patients with HPB diseases.

Clinical correlation of physiological severity (by FFR) and lesion characterization (by IVUS) in non-LMCA intermediate coronary lesions

Percutaneous Transhepatic Biliary Drainage (PTBD) is a procedure indicated in patients with non-operative lesions, when endoscopic application of prosthesis is impossible due to anatomic reasons, complications or severe general condition of patient. Most often it is a palliative procedure, aiming for live-quality improvement, although not altering prognosis of basic disease.This study presents own experience in biliary drainage with the aid of percutaneous transhepatic method and simultaneous assessment of method effectiveness and safety. The aim was to assess outcomes and complications of PTBD in a large group of patients.In time period 2007–2014, 167 patients hospitalized in Radiodiagnostics and Radiology Department of Clinical Hospital, were investigated retrospectively. PTBD procedure was applied to patients with biliary tract obstruction. In total 186 procedures of percutaneous drainage were applied. Average age of patients was 63.6 years. Bilirubin, alkaline phosphatase and gamma-glutamyl transferase were measured before and after procedure. All data were analyzed statistically.In examined group percutaneous drainage was successful in 90.7% interventions. In 8.1% procedures drainage application was ineffective. The most common complication during procedure was hemobilia (3.2%) and the long term complication was drain dislocation (2.7%). The mean bilirubin levels declined from 397.06 μmol/l before drainage to 297.88 μmol/l after drainage (p < 0.05).PTBD is an effective method of biliary tract decompression and it is an important alternative to endoscopic drainage. This method is indicated in patients with neoplastic obstruction of biliary tract with low expected survival rate and thus is a palliative procedure.

Role of percutaneous transhepatic biliary drainage in patients with complications after gastrectomy.

The aim of this study was to elucidate the role of PTBD in patients with DSL and ALS post-gastrectomy for malignancy or benign ulcer perforation. Percutaneous transhepatic biliary drainage (PTBD) is an interventional radiologic procedure used to promote bile drainage. Duodenal stump leakage (DSL) and afferent loop syndrome (ALS) can be serious complications after gastrectomy. From January 2002 through December 2014, we retrospectively reviewed 19 patients who underwent PTBD secondary to DSL and ALS post-gastrectomy. In this study, a PTBD tube was placed in the proximal duodenum near the stump or distal duodenum in order to decompress and drain bile and pancreatic fluids. Nine patients with DSL and 10 patients with ALS underwent PTBD. The mean hospital stay was 34.3 days (range, 12-71) in DSL group and 16.4 days (range, 6-48) in ALS group after PTBD. A liquid or soft diet was started within 2.6 days (range, 1-7) in the ALS group and within 3.4 days (range, 0-15) in the DSL group after PTBD. One patient with DSL had PTBD changed, and 2 patients with ALS underwent additional surgical interventions after PTBD. The PTBD procedure, during which the tube was inserted into the duodenum, was well-suited for decompression of the duodenum as well as for drainage of bile and pancreatic fluids. This procedure can be an alternative treatment for cases of DSL and ALS post-gastrectomy.

Percutaneous Transhepatic Biliary Drainage in Patients with Postsurgical Bile Leakage and Nondilated Intrahepatic Bile Ducts

Objective and Background: Bile leakage is a serious postoperative complication and percutaneous transhepatic biliary drainage (PTBD) may be an option when endoscopic treatment is not feasible. In this retrospective study, we established technical and clinical success rates as well as the complication rates of PTBD in a large group of patients with postoperative bile leakage. Methods: Data on all patients with nondilated intrahepatic bile ducts who underwent a PTBD procedure for the treatment of bile leakage between January 2000 and August 2012 were retrospectively assessed. Data included type of surgery, site of bile leak, previous attempts of bile leak repair, interval between surgery and PTBD placement. Outcome measures were the technical and clinical success rates, the procedure-related complications, and mortality rate. Results: A total of 63 patients were identified; PTBD placement was technically successful in 90.5% (57/63) after one to three attempts. The clinical success rate was 69.8% (44/63). Four major complications were documented (4/63; 6.3%): liver laceration, pneumothorax, pleural empyema, and prolonged hemobilia. One minor complication involved pain. Conclusions: PTBD is an effective treatment with low complication rates for the management of postsurgical bile leaks in patients with nondilated bile ducts.

Intra-biliary contrast-enhanced ultrasound for evaluating biliary obstruction during percutaneous transhepatic biliary drainage: A preliminary study

ObjectivesThe aimed of this study was to investigate the value of intra-biliary contrast-enhanced ultrasound (IB-CEUS) for evaluating biliary obstruction during percutaneous transhepatic biliary drainage (PTBD). Materials and methods80 patients with obstructive jaundice who underwent IB-CEUS during PTBD were enrolled. The diluted ultrasound contrast agent was injected via the drainage catheter to perform IB-CEUS. Both conventional ultrasound and IB-CEUS were used to detect the tips of the drainage catheters and to compare the detection rates of the tips. The obstructive level and degree of biliary tract were evaluated by IB-CEUS. Fluoroscopic cholangiography (FC) and computer tomography cholangiography (CTC) were taken as standard reference for comparison. ResultsConventional ultrasound displayed only 43 tips (43/80, 53.8%) of the drainage catheters within the bile ducts while IB-CEUS identified all 80 tips (80/80, 100%) of the drainage catheters including 4 of them out of the bile duct (P<0.001). IB-CEUS made correct diagnosis in 44 patients with intrahepatic and 36 patients with extrahepatic biliary obstructions. IB-CEUS accurately demonstrated complete obstruction in 56 patients and incomplete obstruction in 21 patients. There were 3 patients with incomplete obstruction misdiagnosed to be complete obstruction by IB-CEUS. The diagnostic accuracy of biliary obstruction degree was 96.3% (77/80). ConclusionIB-CEUS could improve the visualization of the drainage catheters and evaluate the biliary obstructive level and degree during PTBD. IB-CEUS may be the potential substitute to FC in the PTBD procedure.

Debate continues over which method we should prefer for the preoperative biliary decompression in cases with hilar cholangiocarcinoma

Springer 2011 We read with a great interest the article by Kawakami et al. [1] about the best preoperative biliary drainage methods in the management of patients with hilar cholangiocarcinoma (HCA). The authors compared the outcomes of endoscopic nasobiliary drainage (ENBD), endoscopic biliary stenting (EBS) and percutaneous transhepatic biliary drainage (PTBD) in a total of 128 patients. They noted that drainage tube occlusions with cholangitis were more common in the EBS group. They also found that the patients in the PTBD group experienced serious complications including portal vein injury (8%) and cancer dissemination (4%). Finally, they concluded that the ENBD procedure is the best and most suitable method for the initial biliary decompressive approach for the patients with HCA before the resective surgery procedure. Although the retrospective design of this study was already noted to be a limitation, we want to underline some concerns with the results of this study. Indeed, portal vein injury during ultrasound guided PTBD is a very rare occurrence [2]. However, in this report, we noticed a high rate of vascular injury associated with PTBD procedure. The authors did not link this high rate of portal vein injury during PTBD with any explanation in the text. However, we suggest that this complication can be associated with the use of 12–16 Fr tubes which were used for transhepatic cholangioscopy in this study. We think that the authors can provide data about this to make it more clear for the readers. The other flaw with the PTBD procedure is the high rate of tube dislodgement (14%) in this series of the patients. Again, we do not see this rate of tube dislodgement in our daily practice since we use a locked catheter system during internal–external drainage catheter placement to prevent the easy tube dislodgment problem. If the physicians doing the PTBD procedure in this study did not use this system, or they placed mostly external biliary drainage catheters, this might explain this high rate of catheter dislodgement. Thus, we wonder in how many cases they put external and internal catheters during the PTBD procedure. Another unclear point in this study is about their cases with cancer dissemination after the PTBD procedure. The authors indicated cancer dissemination in three patients (6.3%) in association with the PTBD. Although, the cholangiocarcinomas are highly fibrotic tumors with desmoplastic stroma, there is a potential risk of catheter tract implantation [3]. Catheter tract implantation metastasis after PTBD usually presents as subcutaneous nodules. However, it is not clearly indicated in the text how the authors diagnosed and linked cancer dissemination in these cases in association with the PTBD procedure.

Complications of percutaneous transhepatic biliary interventions

Complications of percutaneous transhepatic biliary drainage procedures range from skin discomfort to life-threatening arterial hemobilia. A thorough understanding of biliary anatomy and postprocedure care is essential if such procedures are to be performed. This article summarizes the anatomic, technical, and clinical issues related to biliary interventions and assists the interventional radiologist in the management of complications encountered in patients undergoing biliary interventions.

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.

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.

Superselective arterial embolization in the liver transplant recipient: a safe treatment for hemobilia caused by percutaneous transhepatic biliary drainage.

Transcatheter arterial embolization is widely used to treat life-threatening iatrogenic hemobilia, although in the transplanted liver its use has only been reported in two cases. To evaluate more fully whether transcatheter embolization is safe and effective in transplant recipients, we retrospectively reviewed eight cases of severe hemobilia. These occurred after 128 percutaneous transhepatic biliary drainage procedures performed during a 6-year period. In each case, angiography localized the bleeding to a specific intrahepatic branch that was then subselectively catheterized and occluded by transcatheter embolization. Bleeding was successfully controlled by this method in all eight patients with no immediate complications. The main, right, and left hepatic arteries were shown to be patent immediately after embolization by angiography in all patients. Duplex sonography performed in each case (1 to 4 months) after the procedure confirmed that patency was maintained in all patients. No patients developed liver abscesses, sepsis, or clinical liver infarctions after the embolization. No patients underwent retransplantation after embolization. Our experience shows that superselective transcatheter embolization is a safe, effective therapy to correct iatrogenic hemobilia in the liver transplant recipient without threatening the patency of the major hepatic arteries, the viability of the liver, or the integrity of the biliary tree.

Verschlußikterus: histologische Diagnostik durch perkutane endoluminale Gallengangsbiopsie

32 forceps biopsies were performed in 30 patients with obstructive jaundice during percutaneous transhepatic biliary drainage procedures. In one patient an adequate specimen could not be obtained. In 25 of the remaining 31 cases diagnosis was confirmed histologically (malignant tumours: n = 22, benign stricture: n = 3). In 6 patients false-negative results were obtained. Transluminal biopsy is an easily performed adjunct to percutaneous transhepatic diagnostic interventions with minimal additional discomfort for the patient. In many cases percutaneous needle biopsy can be avoided. Forceps biopsy enables nonoperative histological diagnosis of small carcinomas of the bile ducts.

Infections Associated with Biliary Drainage Procedures in Patients with Cancer

A total of 170 therapeutic biliary drainage procedures were carried out in 90 patients with cancer over a 1-year period (January-December 1988). There were 129 percutaneous transhepatic biliary drainage procedures done in 61 patients and 41 endoprostheses were placed in 29 patients. The overall infection rate related to these procedures was 60.6%, the rate being similar for the two procedures. Infectious complications were experienced by 50% of patients undergoing a biliary drainage procedure. The most common manifestation was cholangitis followed by bacteremia. Other infections included liver abscess, gallbladder abscess, and subphrenic abscess. The most common isolates were enteric gram-negative bacilli, followed by Enterococcus species, Candida species, and Staphylococcus epidermidis. The use of prophylactic antibiotics in 76% of infected patients failed to prevent biliary catheter-related infections. Two patients died of complications related to biliary sepsis. All other infected patients responded to antimicrobial therapy, which included various regimens of beta-lactam agents (third-generation cephalosporin, extended-spectrum penicillin, imipenem-cilastatin, and aztreonam) that were used in combination with an aminoglycoside in 15 patients.

Percutaneous transhepatic cholangiography and biliary drainage after liver transplantation: a five-year experience.

Evaluation of the biliary tract by percutaneous transhepatic cholangiography (PTC) is often required in liver transplant patients with an abnormal postoperative course. Indications for PTC include failure of liver enzyme levels to return to normal postoperatively, an elevation of serum bilirubin or liver enzyme levels, suspected bile leak, biliary obstructive symptoms, cholangitis, and sepsis. Over a 5-year period 625 liver transplants in 477 patients were performed at the University Health Center of Pittsburgh. Fifty-three patients (56 transplants) underwent 70 PTCs. Complications diagnosed by PTC included biliary strictures, bile leaks, bilomas, liver abscesses, stones, and problems associated with internal biliary stents. Thirty-two percutaneous transhepatic biliary drainage procedures were performed. Ten transplantation patients underwent balloon dilatation of postoperative biliary strictures. Interventional radiologic techniques were important in treating other complications and avoiding additional surgery in many of these patients.

The use of Gianturco spirals in percutaneous transhepatic bile duct drainage

One hundred and thirty percutaneous transhepatic biliary drainage procedures have been carried out so far (catheter drainage in 80, biliary endoprostheses in 50 cases). In 36 patients Gianturco coils were introduced into the fistulous tract in order to control severe bleeding and to stop biliary leakage. Three patients of this group had rectifiable complications.

Finger-trap method of suturing biliary drainage catheters to the skin.

With an increasing number of interventional radiologic procedures, many radiologists are becoming involved with interventional catheter management. We have performed 42 percutaneous transhepatic biliary drainage procedures for obstructive jaundice. In three cases the catheters were subsequently pulled out by the patient. Two of these catheters were external drainage catheters and one was internal. Once a biliary drainage catheter has been pulled out, it may be more difficult to regain access to the biliany system if the biliary tree has been decompressed [1 ]. We have developed a method of securing the catheters to the patient’s skin to avoid accidental removal.