Preoperative Percutaneous Transhepatic Biliary Drainage Research Articles

The effect of preoperative percutaneous transhepatic biliary drainage on postoperative short-term outcomes after pancreaticoduodenectomy

Objective To evaluate the effect of preoperative percutaneous transhepatic biliary drainage (PTBD) on postoperative outcomes after pancreaticoduodenectomy.Methods The clinical data of 115 patients undergoing pancreatoduodenectomy between 2001 and 2009 were retrospectively analyzed.The diagnosis of periampullary cancer or cancer of the pancreatic head was confirmed histologically.The preoperative total bilirubin level was more than 100 μmol/L and there was no concomitant cholangitis.Forty-two patients underwent PTBD (PTBD group),and 73 were not drained (early operation group).The following parameters were analyzed:wound infection,intra-abdominal abscess,intra-abdominal or gastrointestinal bleeding,biliary or pancreatic leakage,gastroparesis,morbidity and mortality.The length of hospital stay and cost were also assessed.Results The perioperative mortality and morbidity were 2.38％/54.76％ in the PTBD group and 2.74％/50.68％ in the early operative group,respectively.There were no significantly differences between these two groups.Similar results were obtained in biliary leak,pancreatic leak,intra-abdominal infection,wound infection and gastroparesis.The length of hospital stay and cost were significantly less in the early operation group than the PTBD group.Conclusions PTBD had no beneficial effects on postoperative outcomes following pancreaticoduodenectomy.For distal biliary obstruction,PTBD should not be carried out routinely. Key words: Pancreaticoduodenectomy; Preoperative resolution of jaundice; Percutaneous transhepatic biliary drainage; Postoperative morbidity

Laser-Guided Repair of Complex Bile Duct Strictures

Background: The repair of bile duct strictures (BDS) requires identification of healthy bile duct proximal to the stenosis. Identification may be difficult in complex bile duct injuries after cholecystectomy or partial liver resection. Aim: We describe a technique to identify the prestenotic bile duct using the sentinel light of a laser fiber passed through the catheter after percutaneous transhepatic biliary drainage (PTD). Methods: Seven patients were seen with hepatic duct or segmental BDS after (extended) right hemihepatectomy (4), cholecystectomy (2) or previous hepaticojejunostomy (1). All patients underwent preoperative PTD for imaging of stricture site and drainage. During operation for repair, a laser fiber (0.2–0.6 mm) connected to a (low-power) red light-emitting diode laser was passed through the PTD catheter into the proximal end of the stricture. Results: In 6 patients, the prestenotic bile duct was identified and exposed with the aid of the sentinel light of the laser fiber. Roux-en-Y hepaticojejunostomy was carried out in all patients. Postoperative cholangiographies showed complete restoration of biliary continuity. In one patient, positioning of the laser fiber failed because of angulation of the PTD catheter. Conclusion: Laser-guided identification of prestenotic bile duct facilitates exposure of the stricture site without unnecessary and usually difficult dissection in complex postoperative BDS.

TN01 HILAR CHOLANGIOCARCINOMA: RADIOLOGICAL DIAGNOSIS, STAGING AND PRE‐OPERATIVE INTERVENTION

Hilar intrahepatic cholangiocarcinoma (I‐CAC) accounts for 25% of CAC. Complete surgical resection offers the best possibility of cure but this demands accurate pre‐operative assessment and staging as well as appropriate ancilllary procedures such as selective portal vein embolisation and targeted biliary drainage.CT (MD‐CT) and MRI are the primary imaging modalities used for the assessment of hilar I‐CAC but despite advances in imaging technology, overall accuracy for assessing resectability of hilar I‐CAC is approximately 60–75% for modalities. Hilar I‐CAC may present as thickening of the biliary wall with infltrative margins or (less commonly) a polypoid intra‐ductal or exophyic mass. The mass typically demonstrates delayed enhancement after contrast as a result of the sclerosis and fibrosis of surrounding tissues frequently seen in CAC. The extent of intraductal tumour spread is more accurately demonstrated with MRI/MRCP but the high spatial resolution of MD‐CT allows possibly more accurate definition of vascular invasion and small lymph metastases. These structures may also be evaluated with pre‐operative laparoscopy. CAC is FDG avid and CT‐PET has a role in detecting nodal and peritoneal metastases.Selective pre‐operative percutaneous transhepatic biliary drainage (PTBD) of the obstructed hepatic segments in the future hepatic remnant has been shown to improve post‐operative outcomes. Pre‐operative selective portal vein embolisation has been used to promote hypertrophy in patients with marginal remnant volumes. The degree of compensatory hypertrophy is an important predictor of outcome and is dependant on technical procedural success and underlying liver disease.

Biliary reconstruction and complications of right lobe live donor liver transplantation.

To identify the possible reasons of failure of biliary reconstruction in right lobe live donor liver transplantation (LDLT) and to devise the best method of reconstruction and treatment strategy for the complications. Right lobe LDLT was associated with a high biliary complication rate (15-64%) in the reported series. The causes of failure were not completely understood and the best treatment strategy has not been defined. From 1996 to 2001, 74 patients received right lobe LDLT. The operative procedures of the first 37 patients were critically reviewed to identify the possible reasons of leakage or stenosis from the anastomosis. The causes included right hepatic duct ischemia, double or triple hepaticojejunostomies, unrecognized branch of right hepatic duct, jejunal opening smaller than the size of right hepatic duct, and ductal plasty without division of newly created septum. The second 37 patients had biliary reconstruction by a modified technique that preserved blood supply to the right hepatic duct and aimed at avoidance of risk factors. The overall complication rate decreased from 43% in the first 37 patients to 8% in the second 37 patients. There was no leakage from the anastomosis in the second group of patients. Percutaneous transhepatic biliary drainage (PTBD) for the biliary complications resulted in right portal vein and hepatic artery injury in four patients and accounted for mortality in three of them. To avoid complications from PTBD, three patients in the second group developing stenosis of hepaticojejunostomy had repeated hepaticojejunostomy without preoperative PTBD and recovered. With identification of risk factors and modification of the surgical technique, the complication rate of biliary reconstruction of right lobe LDLT could be reduced. Repeated hepaticojejunostomy without preoperative PTBD is the preferred approach once a complication develops.

The expression levels of plasma membrane transporters in the cholestatic liver of patients undergoing biliary drainage and their association with the impairment of biliary secretory function

OBJECTIVES: Percutaneous transhepatic biliary drainage (PTBD) has been believed to reduce hyperbilirubinemia in patients with obstructive cholestasis and to lessen liver injury through bile acid retention. The efficacy may be closely related to the capability of cholestatic liver to produce and secrete bile, which in turn depends on the expressions and functional activities of plasma membrane transporters in the liver. The aim of the present study was to determine the expression levels of these transporters in the cholestatic liver of patients undergoing PTBD. METHODS: A total of 24 patients who had experienced obstructive cholestasis and had undergone preoperative PTBD were included in the study. Liver biopsy specimens were analyzed to determine the expression levels of the multidrug resistance-associated proteins (MRP) MRP2 and MRP3 and the canalicular bile salt export pump BSEP in the liver. RESULTS: The messenger RNA (mRNA) levels of MRP2, the canalicular bilirubin conjugate export pump, and bile salt export pump (BSEP) were unchanged in liver specimens from the 14 patients well drained by PTBD but were reduced in specimens from the 10 patients poorly drained, compared to the levels of control subjects. Immunostainings of MRP2 and BSEP outlined the canalicular membrane domain but seemed fuzzy to varying degrees in specimens obtained from cholestatic liver, especially in specimens from liver that had been poorly drained, in contrast to the linear and intense localization in the liver of control subjects, correlating with the impaired bilirubin conjugate and bile acid secretion. The mRNA of MRP3, functioning as an inducible export pump for bilirubin conjugate and bile acid, was expressed not only in the cholestatic liver but also in the liver of control subjects, and the mRNA level was increased in specimens from both the cholestatic liver that had been well drained and from the liver that had been poorly drained. Immunostaining of MRP3 was observed in the epithelia of intrahepatic bile ducts in the liver of both control subjects and cholestatic patients, and in the epithelia of proliferated bile ductules and the hepatocytes surrounding the portal tracts in the cholestatic liver. CONCLUSIONS: From the results of the present study, it is concluded that 1) the mRNA and immunohistochemical expression levels of MRP2 and BSEP may be altered in the cholestatic liver of patients undergoing PTBD; 2) both the decreased mRNA levels and the diminished canalicular membrane localization may be associated with the impairment of bile formation and secretion, i.e., the efficacy of PTBD; and 3) upregulated MRP3 in the cholangiocytes and hepatocytes may play a significant role in bile acid transport in the cholestatic hepatobiliary system.

The expression levels of plasma membrane transporters in the cholestatic liver of patients undergoing biliary drainage and their association with the impairment of biliary secretory function

Percutaneous transhepatic biliary drainage (PTBD) has been believed to reduce hyperbilirubinemia in patients with obstructive cholestasis and to lessen liver injury through bile acid retention. The efficacy may be closely related to the capability of cholestatic liver to produce and secrete bile, which in turn depends on the expressions and functional activities of plasma membrane transporters in the liver. The aim of the present study was to determine the expression levels of these transporters in the cholestatic liver of patients undergoing PTBD. A total of 24 patients who had experienced obstructive cholestasis and had undergone preoperative PTBD were included in the study. Liver biopsy specimens were analyzed to determine the expression levels of the multidrug resistance-associated proteins (MRP) MRP2 and MRP3 and the canalicular bile salt export pump BSEP in the liver. The messenger RNA (mRNA) levels of MRP2, the canalicular bilirubin conjugate export pump, and bile salt export pump (BSEP) were unchanged in liver specimens from the 14 patients well drained by PTBD but were reduced in specimens from the 10 patients poorly drained, compared to the levels of control subjects. Immunostainings of MRP2 and BSEP outlined the canalicular membrane domain but seemed fuzzy to varying degrees in specimens obtained from cholestatic liver, especially in specimens from liver that had been poorly drained, in contrast to the linear and intense localization in the liver of control subjects, correlating with the impaired bilirubin conjugate and bile acid secretion. The mRNA of MRP3, functioning as an inducible export pump for bilirubin conjugate and bile acid, was expressed not only in the cholestatic liver but also in the liver of control subjects, and the mRNA level was increased in specimens from both the cholestatic liver that had been well drained and from the liver that had been poorly drained. Immunostaining of MRP3 was observed in the epithelia of intrahepatic bile ducts in the liver of both control subjects and cholestatic patients, and in the epithelia of proliferated bile ductules and the hepatocytes surrounding the portal tracts in the cholestatic liver. From the results of the present study, it is concluded that 1) the mRNA and immunohistochemical expression levels of MRP2 and BSEP may be altered in the cholestatic liver of patients undergoing PTBD; 2) both the decreased mRNA levels and the diminished canalicular membrane localization may be associated with the impairment of bile formation and secretion, i.e., the efficacy of PTBD; and 3) upregulated MRP3 in the cholangiocytes and hepatocytes may play a significant role in bile acid transport in the cholestatic hepatobiliary system.

Biliary indocyanine green excretion as a predictor of hepatic adenosine triphosphate levels in patients with obstructive jaundice

Background: Correlation of the hepatic adenosine triphosphate (ATP) level with indocyanine green (ICG) excretion into bile was examined in patients with obstructive jaundice after the relief of hyperbilirubinemia by preoperative percutaneous transhepatic biliary drainage (PTBD). Methods: Patients with complete bile duct obstruction, the mean serum total bilirubin concentration being 13.6 ± 8.5 (SD) mg/dL, underwent PTBD prior to surgery. Within a few days before surgery when the mean serum total bilirubin level decreased to 1.2 mg/dL, ICG (0.5 mg/kg) was intravenously injected, and the whole bile was collected at 1-hour intervals for 5 hours. The ICG concentration in bile, bile flow rate, amount of ICG excreted in bile, and biliary ICG excretion rate as percentage of the injected dose were determined. At the time of surgery, a small liver tissue sample was obtained immediately after laparotomy without any ischemic procedures, and ATP concentrations were determined. Results of hepatic ATP levels were correlated with laboratory and clinical determinations. Results: The bile flow rate was essentially constant during the 5-hour period, the mean value being 21 mL/hour. The ICG concentrations in bile gradually increased, reached the maximal level in 3 hour, and declined thereafter. The biliary ICG excretion rate for 5 hours was 40% ± 18% of its injected dose. The biliary ICG excretion rate and amount of ICG excreted in bile for 5 hours significantly ( P <0.05) correlated with the hepatic ATP level. The decline index of serum bilirubin during PTBD was also correlated with the hepatic ATP level. The serum ICG retention rate, bile flow rate, maximal ICG concentration in bile, and other liver function tests including serum albumin and cholinesterase levels did not correlate with the hepatic ATP level. Conclusions: Both the amount of and excretion rate of ICG in bile reflect the hepatic ATP level. Determination of biliary ICG excretion contributes to precise evaluation of hepatic energy status before surgery in patients with obstructive jaundice.

SIGNIFICANCE OF PREOPERATIVE PERCUTANUOUS TRANSHEPATIC BILIARY DRAINAGE FOR OBSTRUCTIVE JAUNDICE

Eighty-five patients, with malignant obstructive jaundice whose serum T-bilirubin (T-Bil) were less than 10 mg/dl were allocated to pancreaticoduodenectomy. In order to study the significance of the preoperative percutaneous transhepatic biliary drainage (PTBD), the 85 patients were divided into 3 groups according to serum T-Bil level, namely, group A comprising of 26 with serum T-Bil levels of more than 3mg/dl with preoperative PTBD; group B comprising of 9 with the levels of more than 3mg/dl without PTBD; and group C comprising of 50 with the levels of lesser than 3mg/dl without PTBD. Furthermore, complications of PTBD were evaluated in 469 patients with benign or malignant obstructive jaundice for the same period. After pancreaticoduodenectomy the morbidity was 23% in group A, 22% in group B, or 30% in group C, while the mortality was 8%, 0%, or 4% respectively, with no remarkable difference. These figures might indicate operative risks themselves. On the other hand, post-PTBD morbidity was not so low as 16.8% and the mortality 1.1%. Preoperative PTBD did not reduce operative risks. Therefore in patients with malignant biliary obstruction presenting serum T-Bil levels of less than 10mg/dl, pancreaticoduodenectomy should be performed without preoperative PTBD.

The role of preoperative biliary decompression in the treatment of bile duct cancer.

AbstractUsefulness of preoperative biliary decompression by percutaneous transhepatic biliary drainage (PTBD) in patients with obstructive jaundice remains controversial. We determined bile and bile acid outputs in patients with complete biliary obstruction following biliary decompression by PTBD. Bile and bile acid outputs correlated well with the decline index of serum bilirubin. Patients with a poor decline index tended to have low bile acid output in spite of high bile output, i.e., secretion of watery bile. Daily bile acid output reflecting daily bile acid synthesis remained low or increased only slowly in almost all cases, indicating that recovery of liver function is considerably delayed. We stress the importance of bile acid output as a function of bile acid synthesis as an index of the recovery of liver function. Although many studies comparing operative intervention alone and PTBD followed by operation have already been carried out, and because of the increasing use and greater safety of a 2‐staged approach with ultrasound‐guided PTBD, the advantages and disadvantages of preoperative PTBD should continue to be reevaluated with respect to technical improvement and a concomitant decrease in complications.

Percutaneous Transhepatic Biliary Drainage

Percutaneous transhepatic biliary drainage is usually used for preoperative decompression and for palliation in obstructive jaundice, but little attention has been focused on catheter complications. We retrospectively reviewed our experience with percutaneous transhepatic biliary drainage in 81 consecutive patients. There was a 10.0% failure rate and an 8.6% mortality rate. Four patients (4.9%) required emergency operations for complications and an additional ten patients (12.3%) required transfusions. The overall sepsis rate was 34.6%; prophylactic antibiotics decreased the sepsis rate. Thirty-eight patients (47.0%) required 68 manipulation procedures for catheter malfunctions. No distinguishing characteristics could be found to identify the subgroups having complications or mortalities. The efficacy of preoperative percutaneous transhepatic biliary drainage has not been proved, and the indications for palliation are not clearly defined. Further trials are needed to define the role of percutaneous transhepatic biliary drainage in patients with obstructive jaundice.

Antipyrine elimination in patients with obstructive jaundice: A predictor of outcome

A number of factors are known to be related to increased mortality of surgery in obstructive jaundice, yet precise identification of patients at greatest risk is difficult. We have studied the elimination of the minor analgesic antipyrine as a dynamic measure of hepatic metabolic function in patients with obstructive jaundice undergoing percutaneous transhepatic biliary drainage. Of 46 patients in whom antipyrine clearance was measured, 21 had an antipyrine half-life less than 15 hours and 2 died in the hospital. Of 25 who had an antipyrine half-life greater than 15 hours, 10 died in the hospital, 4 before undergoing surgery. The difference in mortality is significant (p less than 0.05). Of 15 patients who had serial antipyrine tests, only 4 showed an improvement during percutaneous transhepatic biliary drainage. The antipyrine test may be a useful predictor of outcome in obstructive jaundice, and this study suggests that hepatic function does not improve in all patients undergoing preoperative percutaneous transhepatic biliary drainage.

Routine preoperative biliary drainage: effect on management of obstructive jaundice.

The routine application of preoperative percutaneous transhepatic biliary drainage (PTBD) to patients who have obstructive jaundice has a significant effect on overall morbidity, mortality, and patient survival by allowing selective application of the most appropriate therapeutic modality. Surgical patients who undergo PTBD were compared with those for whom PTBD was not available. The surgical complication rate was 44% for those who did not undergo PTBD and 15% for those who did. The surgical procedure-related mortality rate was 30% for those who did not undergo PTBD and 12% for those who did. These differentials may have been due either to a beneficial effect of presurgical decompression or to the fact that only more favorable candidates were selected for operative internal bypass. There was an overall increase in length of survival following the application of PTBD, especially in those patients who were surgical candidates.