Target Bile Duct Research Articles

Usefulness of endoscopic ultrasound-guided transhepatic biliary drainage with a 22-gauge fine-needle aspiration needle and 0.018-inch guidewire in the procedure's induction phase.

Endoscopic ultrasound (EUS)-guided transhepatic biliary drainage is usually performed with a 19-gauge fine-needle aspiration (FNA) needle and a 0.025-inch guidewire. The combination of a 22-gauge FNA needle and a 0.018-inch guidewire is reported to be effective as a rescue option when the bile duct diameter is small or technically challenging. Experts in EUS-guided transhepatic biliary drainage have reported that bile duct puncture with a 19-gauge FNA needle is possible in most cases, but is not easy to reproduce by endoscopists with less experience in EUS-guided transhepatic biliary drainage. We investigated the usefulness of EUS-guided transhepatic biliary drainage using a 22-gauge FNA needle and a 0.018-inch guidewire during the procedure's induction phase. Consecutive patients who underwent EUS-guided transhepatic biliary drainage at our institution from March 2021 to May 2023 were evaluated, and 37 were included. Biliary drainage was performed for malignant bile duct stricture in 36 patients and choledocholithiasis in one patient. The median target bile duct diameter was 4.5 mm (2.5-9.4). Biliary access, fistula dilation, and stent placement were successful in the 37 patients (100%). The median procedure time was 35 min (16-125). Adverse events occurred in four (10.8%) patients. EUS-guided transhepatic biliary drainage using a 22-gauge FNA needle and a 0.018-inch guidewire is a useful and promising option for endoscopists with limited experience in EUS-guided transhepatic biliary drainage in the procedure's induction phase.

Su1523 A COMBINED SIDE-BY-SIDE AND STENT-IN-STENT METHOD FOR TRIPLE METAL STENTING IN PATIENTS WITH MALIGNANT HILAR BILIARY OBSTRUCTION

Self-expandable metal stent (SEMS) placement is recommended for unresectable malignant hilar biliary obstructions (MHBOs), and a recent randomized study showed that bilateral SEMS placement resulted in fewer reinterventions and better stent patency than unilateral SEMS placement. Although bilateral placement of 2 stents is sufficient in many cases, the placement of 3 or more stents is sometimes needed in high-grade MHBOs because of insufficient drainage and/or segmental cholangitis. However, endoscopic placement of 3 branched SEMSs is technically challenging. We examined the feasibility and efficacy of a novel stenting method combining side-by-side and stent-in-stent (SBSIS) placement for MHBO. Between January 2015 and April 2019, 30 consecutive patients with high-grade MHBO underwent SBSIS placement. Following insertion of the 0.025-inch guidewires into the 3 target intrahepatic bile ducts across the stricture, 2 SEMSs delivery systems were simultaneously inserted over the guidewires. The stents were released concurrently or one-by-one and placed in the side-by-side configuration above the level of the duodenal papilla with their distal ends at the same level. The third target bile duct is reached with the guidewire via the mesh of the stent in the same hepatic side, using the initially placed guidewire of the third target duct as a landmark. The third SEMS was subsequently inserted over the guidewire and placed across the stent mesh and the stricture in the partial stent-in-stent configuration. We evaluated the technical success, functional success, recurrent biliary obstruction (RBO), adverse events other than RBO, and reintervention success rates associated with SBSIS placement. The technical success rate was 87% (26/30). Insertion of the third SEMS failed in 4 patients, and the median diameter of the common bile duct (CBD) was significantly smaller in patients in whom technical failure occurred (5 mm vs. 8 mm; P = 0.003). Functional success was achieved in all patients in whom the procedure was a technical success. The rate of adverse events other than RBO was 13% (4/30). As early adverse events, cholangitis and aspiration pneumonia occurred in 1 patient each. As late adverse events, cholecystitis and non-occlusion cholangitis occurred in 1 patient each. The RBO rate was 38% (10/26), and the median time to RBO was 170 days. The success rate of endoscopic reintervention for RBO was 89% (8/9). SBSIS placement showed favorable results and is a promising option in patients with high-grade MHBO requiring triple metal stenting. This method can reduce technical difficulty by avoiding inability of second SEMS placement and reducing the number of passes through the stent mesh. However, if the CBD diameter is narrow, this procedure might not be suitable.

The ultrasonic navigation technique in percutaneous transhepatic one-step biliary fistulation with rigid cholangioscopic lithotripsy for complicated hepatolithiasis

Objective To study the efficacy and safety of percutaneous transhepatic one-step biliary fistulation (PTOBF) with rigid cholangioscopic lithotripsy for treatment of complicated hepatolithiasis under the ultrasonic navigation technique. Methods In this retrospective study, PTOBF lithotripsy surgery was performed in 94 patients with hepatolithiasis under general anesthesia with tracheal intubation, and with percutaneous transhepatic puncture of targeted bile duct under ultrasonic navigation in The First Affiliated Hospital of Guangzhou Medical University. Biliary expanders were used along a guidewire to expand the sinus gradually until 14Fr to establish a fistulous channel. Lithotripsy was then performed through the channel by rigid cholangioscopy. The operation-related data were collected and analyzed, including puncture and fistula establishment success ratio, complication rate, intraoperative blood loss, residual and recurrence hepatolithiasis rates. Results 94 patients (total 122 patient-times) underwent PTOBF lithotripsy. There was no perioperative mortality. The overall puncture success rate was 100%, and the fistula/puncture rate was 97.5% (119/122). In 118 patients success was achieved in 2 time (96.7%). The complication rate was 9.6% (9/94). The average intraoperation blood loss were (24.9±21.3)ml. The residual calculus rate after therapy was 13.8%(13/94). All patients were followed-up for a period that ranged between 18 and 30 months. The recurrence rate was 14.9%(14/94). Conclusions Ultrasonic navigation technique plays an important role in bile duct puncture, sinus expansion and rigid cholangioscopic lithotripsy for treatment of complicated hepatolithiasis. PTOBF lithotripsy is a safe and effective procedure, which provides a new way in mini-invasive treatment for hepatolithiasis. It is worth generalizing. Key words: Ultrasound; Navigation; Percutaneous transhepatic puncture; Hepatolithiasis; Rigid cholangioscope

Percutaneous transhepatic choledochoscopic lithotripsy and Interventional radiology techniques hybrid procedure in treatment of complex recurrent hepatolithiasis

Hepatolithiasis is a complex disease with a high recurrence rate, and may lead to recurrent cholangitis, biliary cirrhosis and cholangiocarcinoma. Traditional surgery to treat hepatolithiasis has its shortcomings such as causing injury and incomplete removal of stones. Percutaneous transhepatic choledochoscopic lithotripsy (PTCSL) is a safe and reliable method for hepatolithias causing minimal trauma, a fast recovery and a small incision. Cholangioscopes and ureteroscope inability to reach the target bile duct is usually due to the difficult acute angle of bile duct caused by biliary stricture and biliary fibrosis. We used PTCSL in conjunction with interventional radiology (IR) techniques and Endoscopic retrograde cholangiopancreatography (ERCP) accessories for this situation and achieved an effective stone clearance.

Vaccination of hamsters with Opisthorchis viverrini extracellular vesicles and vesicle-derived recombinant tetraspanins induces antibodies that block vesicle uptake by cholangiocytes and reduce parasite burden after challenge infection.

BackgroundThe liver fluke Opisthorchis viverrini infects several million people in Southeast Asia. Adult flukes live in the bile ducts of humans, where they cause hepatobiliary pathology, including cholangiocarcinoma. Here, we investigated the potential of extracellular vesicles (EVs) secreted by the fluke and defined recombinant proteins derived from EVs to generate protective immunity in a hamster vaccination-challenge model.Methodology/Principal findingsEVs isolated from the excretory-secretory products of O. viverrini and two recombinant EV surface proteins encoding the large extracellular loops (LEL) of Ov-TSP-2 (rOv-TSP-2) and Ov-TSP-3 (rOv-TSP-3) were adjuvanted and used to vaccinate hamsters intraperitoneally followed by challenge infection with O. viverrini metacercariae. The number of adult flukes recovered from hamsters immunized with EVs, rOv-TSP-2, rOv-TSP-3 and rOv-TSP-2+rOv-TSP-3 were significantly reduced compared to control animals vaccinated with adjuvant alone. The number of eggs per gram feces was also significantly reduced in hamsters vaccinated with rOv-TSP-2 compared to controls, but no significant differences were found in the other groups. The average length of worms recovered from hamsters vaccinated with EVs, rOv-TSP-2 and rOv-TSP-3 was significantly shorter than that of worms recovered from the control group. Anti-EV IgG levels in serum and bile were significantly higher in hamsters vaccinated with EVs compared to control hamsters both pre- and post-challenge. In addition, levels of anti-rOv-TSP antibodies in the serum and bile were significantly higher than control hamsters both pre- and post-challenge. Finally, antibodies against rOv-TSP-2 and rOv-TSP-3 blocked uptake of EVs by human primary cholangiocyte in vitro, providing a plausible mechanism by which these vaccines exert partial efficacy and reduce the intensity of O. viverrini infection.Conclusion/SignificanceLiver fluke EVs and recombinant tetraspanins derived from the EV surface when administered to hamsters induce antibody responses that block EV uptake by target bile duct cells and exert partial efficacy and against O. viverrini challenge.

Ethanol ablation for refractory bile leakage after complex hepatectomy

BACKGROUND Only a few reports exist on the use of ethanol ablation for posthepatectomy bile leakage. The aim of this study was to assess the value of ethanol ablation in refractory bile leakage. METHODS Medical records of consecutive patients who underwent a first hepatobiliary resection with bilioenteric anastomosis between 2007 and 2016 were reviewed retrospectively, with special attention to bile leakage and ethanol ablation therapy. Bile leakage was graded as A/B1/B2 according to the International Study Group of Liver Surgery definition. Absolute ethanol was injected into the target bile duct during fistulography. RESULTS Of the 609 study patients, 237 (38·9 per cent) had bile leakage, including grade A in 33, grade B1 in 18 and grade B2 in 186. Left trisectionectomy was more often associated with grade B2 bile leakage than other types of hepatectomy (P < 0·001). Of 186 patients with grade B2 bile leakage, 31 underwent ethanol ablation therapy. Ethanol ablation was started a median of 34 (range 15-122) days after hepatectomy. The median number of treatments was 3 (1-7), and the total amount of ethanol used was 15 (3-71) ml. Complications related to ethanol ablation included transient fever (27 patients) and mild pain (13). Following ethanol ablation, bile leakage resolved in all patients and drains were removed. The median interval between the first ablation and drain removal was 28 (1-154) days. CONCLUSION Ethanol ablation is safe and effective, and may be a treatment option for refractory bile leakage.

Ethanol ablation for refractory bile leakage after complex hepatectomy.

Only a few reports exist on the use of ethanol ablation for posthepatectomy bile leakage. The aim of this study was to assess the value of ethanol ablation in refractory bile leakage. Medical records of consecutive patients who underwent a first hepatobiliary resection with bilioenteric anastomosis between 2007 and 2016 were reviewed retrospectively, with special attention to bile leakage and ethanol ablation therapy. Bile leakage was graded as A/B1/B2 according to the International Study Group of Liver Surgery definition. Absolute ethanol was injected into the target bile duct during fistulography. Of the 609 study patients, 237 (38·9 per cent) had bile leakage, including grade A in 33, grade B1 in 18 and grade B2 in 186. Left trisectionectomy was more often associated with grade B2 bile leakage than other types of hepatectomy (P < 0·001). Of 186 patients with grade B2 bile leakage, 31 underwent ethanol ablation therapy. Ethanol ablation was started a median of 34 (range 15-122) days after hepatectomy. The median number of treatments was 3 (1-7), and the total amount of ethanol used was 15 (3-71) ml. Complications related to ethanol ablation included transient fever (27 patients) and mild pain (13). Following ethanol ablation, bile leakage resolved in all patients and drains were removed. The median interval between the first ablation and drain removal was 28 (1-154) days. Ethanol ablation is safe and effective, and may be a treatment option for refractory bile leakage.

Application of 3D visualization and 3D printing technology on ERCP for patients with hilar cholangiocarcinoma.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important treatment for inoperable hilar cholangiocarcinoma (HCC). The aim of the present study as to evaluate the clinical value of three-dimensional visualization (3DV) and 3D printing (3DP) technologies for ERCP in patients with HCC. The clinical data of 15 patients with HCC admitted for ERCP were analyzed retrospectively, including 9 males and 6 females. Thin-sliced data of computed tomography and magnetic resonance cholangiopancreatography (MRCP) were acquired and imported into Mimics Innovation Suite v17.0 software for 3D reconstruction. Standard Template Library files were exported for 3D printing. The target bile duct and Bismuth-Corlette (BC) classification were selected and performed respectively with the aid of Mimics Innovation Suite v17.0 software. The results were compared with the selected ones in ERCP. 3DV and 3DP models were successfully constructed for all patients, which presented the tumor, bile duct and the spatial relationship between them from multiple perspectives. The ERCP of all patients in the present study were performed successfully. The target bile duct screened by them had a high concordance rate of 86.7% with that in ERCP. The diagnostic accuracy of BC type results by 3DV and 3DP models was 93.3%. 3DV and 3DP technologies can accurately show the tumor and its associations with the surrounding bile duct, and it can be used to guide ERCP in HCC patients and improve the success rate of the operation.

The Usefulness of Virtual Fluoroscopic Preprocedural Planning During Percutaneous Transhepatic Biliary Drainage.

To retrospectively evaluate the usefulness of virtual fluoroscopic preprocedural planning (VFPP) in the percutaneous transhepatic biliary drainage (PTBD) procedure. Twenty-two patients who were treated by PTBD were included in this study. Twelve patients were treated using PTBD intraoperative referencing coronal computed tomography (CT) images (i.e., coronal CT group), and ten patients were treated using PTBD intraoperative referencing VFPP images (i.e., VFPP group). To analyze the effect of the intraoperative referencing VFPP image, the VFPP group was retrospectively compared with the coronal CT group. The characteristics of both patient groups were not statistically significantly different. There were no significant differences in the targeted bile duct, diameter and depth of the target bile, breath-holding ability, number of targeted bile duct puncture attempts, change in the targeted bile duct, and exchange of the drainage catheter. However, the X-ray fluoroscopy time and the procedure time were significantly shorter in the VFPP group than in the coronal CT group (196 vs. 334s, P<0.05; and 16.0 vs. 27.2min, P<0.05). Intraoperative referencing using the VFPP imaging in PTBD intuitively can be a useful tool for better localization of the guidewire in the bile duct and thereby shorten the X-ray fluoroscopy time and procedure time while minimizing radiation exposure and complications.

Direct retrograde cholangioscopy with a new prototype double-bending cholangioscope.

Direct retrograde cholangioscopy (DRC) enables high quality video imaging of the bile ducts and allows intraductal treatment with optical control. We evaluated the feasibility, success, and complications of a new third-generation prototype cholangioscope. All consecutive patients from two tertiary endoscopy centers who had undergone DRC with the prototype were included. Indications for DRC were: evaluation of indeterminate strictures, filling defects, and complex bile duct stones. Technical success was investigated in terms of indication and treatment performed. All adverse events were recorded. DRC with the prototype was performed in 74 patients. Therapeutic interventions included laser or electrohydraulic lithotripsy and stone removal, among others. The papilla was entered in 72/74 patients (97 %). The targeted bile duct segment was reached in 62 /74 patients (84 %), with an anchoring balloon catheter needed in 21/74 (28 %). Mean investigation time was 21 minutes (15 - 27 minutes) DRC using the prototype is feasible, safe, and attains access to the bile ducts in almost all patients, with less need of an anchoring balloon catheter compared with the standard technique and short investigation and fluoroscopy times.

Interventional MRI-guided local delivery of agents into swine bile duct walls using MR-compatible needle-integrated balloon catheter system.

The purpose of this study was to investigate the feasibility of interventional MRI-guided local agent delivery into pig common bile duct (CBD) walls using a newly designed MR-compatible, needle-integrated balloon catheter system. We first designed a needle-integrated balloon catheter system that comprised of a 22 G MR-compatible Chiba biopsy needle and a conventional 12 mm × 2 cm balloon catheter. Under fluoroscopy guidance, a custom needle-balloon system was positioned in the target CBD via a transcholecystic access. T1-weighted MRI was used to localize and reposition the needle-balloon system in the target. A 0.5 mL mixture of motexafin gadolinium (MGd) and trypan blue dye as well as 5-fluorouracil was delivered into the CBD wall through the needle-balloon system. Post-infusion T1-weighted MRI was obtained and contrast-to-noise ratios (CNRs) of CBD walls of pre- and post-MGd-blue infusions were compared by a paired t-test. In addition, post-infusion x-ray cholangiography was achieved to evaluate the potential injuries of CBDs by the needle-balloon system. Subsequent histologic analysis was performed to correlate and confirm the imaging findings. A post-infusion cholangiogram did not show any extravasation of contrast agent, indicating no procedure-related damage to the CBDs. MRI demonstrated clear enhancement of the target bile duct walls infused with MGd-trypan blue dye with average penetration depth of 4.7 ± 1.2 mm and an average MGd perfusion length of 21 ± 1.5 mm in the bile ducts and their surrounding tissues. The average CNR of the post-infusion bile ducts was significant higher than that of the pre-infusion bile ducts (110.6 ± 22 versus 5.7 ± 2.8, p < 0.0001). Histology depicted the blue dye staining and red fluorescence of MGd through the target CBD walls, which was well correlated with the imaging findings. It is feasible to use the new MR-compatible, needle-integrated balloon catheter system for intrabiliary local agent delivery into CBD walls under MRI guidance, which may open new avenues for efficient management of pancreatobiliary malignancies using MR-guided interventional oncology.

Percutaneous transhepatic biliary drainage assisted by real-time virtual sonography: a retrospective study

BackgroundReal-time virtual sonography (RVS) is a diagnostic imaging support system that can synchronize with ultrasound images in conjunction with computed tomography or magnetic resonance images using magnetic navigation system. RVS has been applied in clinical practice to perform such procedures as radiofrequency ablation and biopsy; however, the application of RVS for percutaneous transhepatic biliary drainage (PTBD) is rare.MethodsBetween 2007 and 2012, RVS-assisted PTBD was performed for 30 patients (19 males and 11 females; age range, 41 to 89 years; mean age, 66.9 years) with obstructive jaundice. The targeted bile duct was determined using the RVS system before the procedure. The intervention was considered to be successful when the targeted bile duct was punctured and the drainage catheter was placed in the bile duct. Complications were evaluated according to the Society of Interventional Radiology Clinical Practice Guidelines.ResultsA total of 37 interventions were performed for 30 patients. The interventions were successful in 35 (95%) of 37 interventions. The targeted bile ducts were: B3 (n = 24), B5 (n = 7), B8 (n = 3), B6 (n = 1), and the anterior (n = 1) and posterior (n = 1) branches of the right bile duct. The mean targeted bile duct diameter was 4.9 mm (1.9 to 8.2 mm). PTBD was able to be accomplished in all patients because the non-targeted bile ducts were successfully punctured alternatively. No major complications were observed in relation to the interventional procedure.ConclusionsRVS-assisted PTBD is a feasible and safe procedure. Accurate puncture of targeted bile ducts can be achieved using this method.

Mini direct cholangioscopy and direct targeted bile duct biopsies using a laser fiber through a biliary catheter

Mini direct cholangioscopy and direct targeted bile duct biopsies using a laser fiber through a biliary catheter

Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography

To investigate the clinical outcome of double balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) in patients with altered gastrointestinal anatomy. Between September 2006 and April 2011, 47 procedures of DB-ERCP were performed in 28 patients with a Roux-en-Y total gastrectomy (n = 11), Billroth II gastrectomy (n = 15), or Roux-en-Y anastomosis with hepaticojejunostomy (n = 2). DB-ERCP was performed using a short-type DBE combined with several technical innovations such as using an endoscope attachment, marking by submucosal tattooing, selectively applying contrast medium, and CO₂ insufflations. The papilla of Vater or hepaticojejunostomy site was reached in its entirety with a 96% success rate (45/47 procedures). There were no significant differences in the success rate of reaching the blind end with a DBE among Roux-en-Y total gastrectomy (96%), Billroth II reconstruction (94%), or pancreatoduodenectomy (100%), respectively (P = 0.91). The total successful rate of cannulation and contrast enhancement of the target bile duct in patients whom the blind end was reached with a DBE was 40/45 procedures (89%). Again, there were no significant differences in the success rate of cannulation and contrast enhancement of the target bile duct with a DBE among Roux-en-Y total gastrectomy (88 %), Billroth II reconstruction (89%), or pancreatoduodenectomy (100%), respectively (P = 0.67). Treatment was achieved in all 40 procedures (100%) in patients whom the contrast enhancement of the bile duct was successful. Common endoscopic treatments were endoscopic biliary drainage (24 procedures) and extraction of stones (14 procedures). Biliary drainage was done by placement of plastic stents. Stones extraction was done by lithotomy with the mechanical lithotripter followed by extraction with a basket or by the balloon pull-through method. Endoscopic sphincterotomy was performed in 14 procedures with a needle precutting knife using a guidewire. The mean total duration of the procedure was 93.6 ± 6.8 min and the mean time required to reach the papilla was 30.5 ± 3.7 min. The mean time required to reach the papilla tended to be shorter in Billroth II reconstruction (20.9 ± 5.8 min) than that in Roux-en-Y total gastrectomy (37.1 ± 4.9 min) but there was no significant difference (P = 0.09). A major complication occurred in one patient (3.5%); perforation of the long limb in a patient with Billroth II anastomosis. Short-type DBE combined with several technical innovations enabled us to perform ERCP in most patients with altered gastrointestinal anatomy.

Ultrasound and fluoroscopy guided percutaneous transhepatic biliary drainage in patients with nondilated bile ducts

The purpose of this study is to demonstrate the feasibility, safety, and success of percutaneous transhepatic biliary drainage (PTBD) using a combination of ultrasound and fluoroscopy guidance in patients with nondilated bile ducts. Between January 2005 and July 2007, 50 patients with nondilated bile ducts underwent ultrasound-and-fluoroscopy guided PTBD. The underlying disease processes were divided into biliary obstruction (n = 38) and bile leakage (n = 12). We used ultrasound guidance when puncturing a bile duct and during cholangiography. We punctured along the course of the targeted bile duct or portal vein when the bile duct was not visualized, which we termed the "parallel technique." This method made it possible for us to cannulate the peripheral bile duct successfully, even when its course was not visualized well by sonography. We then installed a drainage catheter under fluoroscopy guidance. The technical success and complications of the procedure were evaluated. Neither significant complications nor technical failures were observed. There were only four minor complications: transient hemobilia (n = 3) and fever (n = 1). Ultrasound-and-fluoroscopy guided PTBD in patients with nondilated bile ducts is a safe, feasible, and efficient procedure for the palliation of biliary obstruction and leakage.

Effectiveness of chemical biliary duct embolization for chemical hepatectomy

The high recurrence of hepatolithiasis and high operative trauma of hepatectomy necessitate new therapeutic approaches. Thus, this study was designed to (i) investigate the effectiveness of chemical biliary duct embolization (CBDE) for chemical hepatectomy; and (ii) to determine the mechanism of CBDE. The median biliary ducts in rats were injected with phenol or absolute ethanol alone, or in conjunction with cyanoacrylate. The effectiveness of CBDE for chemical hepatectomy was assessed by investigating histology, in situ hybridization for Fas and transforming growth factor (TGF)-beta1, immunohistochemistry for alpha-smooth muscle actin, and reverse transcription-polymerase chain reaction (RT-PCR) for procollagen I mRNA. Histologically, phenol or absolute ethanol plus cyanoacrylate could embolize the targeted bile duct and promote hepatic fibrosis and atrophy in the embolized lobe better than using phenol or ethanol alone. In addition, CBDE accelerated hepatocellular apoptosis via up-regulation of Fas, thereby resulting in the death of hepatocytes, which were replaced by proliferative bile ductules and collagen. Importantly, the hepatocytes disappeared completely in the periphery of the embolized lobe, thus achieving the desired effects of chemical hepatectomy. Further investigation indicated that CBDE initiated progressive fibrogenic processes of chemical hepatectomy via up-regulation of TGF-beta1, which greatly enhanced the synthesis of collagen. Indeed, higher levels of TGF-beta1 and procollagen I mRNA were observed in the phenol embolization group than in any other group. Chemical biliary duct embolization, especially using phenol plus cyanoacrylate, might achieve the effects of chemical hepatectomy.