Transhepatic Approach Research Articles

Long-term outcome of endoscopic and/or percutaneous transhepatic therapy in patients with biliary stricture after orthotopic liver transplantation

Biliary strictures are a serious complication after liver transplantation. Endoscopic and percutaneous transhepatic procedures have gained an increasing potential for the management of this problem. Long-term follow-up of endoscopic and/or percutaneous transhepatic therapy of biliary strictures after liver transplantation was evaluated. Between January 1996 and December 2007, 47 patients with biliary stricture after liver transplantation were identified by analysing the endoscopic database, hospital charts and cholangiograms. Long-term follow-up was evaluated using cholangiograms, transabdominal ultrasound, laboratory parameters and physical examination. The type of biliary stricture after liver transplantation was subdivided into anastomotic stricture (n = 29), non-anastomotic stricture (n = 14) and bilioenterostomy stricture (n = 4). Of the patients, 38/47 were treated by endoscopic procedures (ERCP), and 9/47 patients were treated by percutaneous transhepatic procedures (PTBD). In 2 of 47 patients combined approaches (rendezvous technique) were performed. Overall, 23/29 patients in the anastomotic group, 12/14 patients in the non-anastomotic group, and 3/4 patients in the bilioenterostomy group had successfully completed endoscopic and/or percutaneous transhepatic therapy. Biliary drainage could be respectively terminated after median 9 (1-83), 11 (1-89) and 10 (4-14) months. Endoscopic as well as percutaneous transhepatic approaches in combination or as monotherapy are effective in the management of anastomotic and non-anastomotic strictures after liver transplantation.

Embolization of Rectal Varices via a Paraumbilical Vein with an Abdominal Wall Approach in a Patient with Massive Ascites

The standard treatment for rectal varices has not been established, as serious rectal varices causing massive hemorrhage are rare. Previously reported treatments for the varices include endoscopic sclerotherapy, transjuglar intravenous portosystemic shunt (TIPS) placement to decrease the portal venous pressure (1), and embolization with a transhepatic (2) or TIPS approach (3). Herein, we report on a patient with rectal variceal bleeding that was controlled with embolization via the paraumbilical vein (PUV).

High dorsal resection for recurrent hepatocellular carcinoma originating in the caudate lobe

Standards that enable surgeons to balance radical operative procedures with functional preservation for recurrent hepatocellular carcinoma (HCC) in the caudate lobe have not yet been established. A 54-year-old man with recurrent HCC originating in the caudate lobe was readmitted to our hospital. The combined resection of the adjacent hepatic parenchyma may have carried a risk of postoperative liver failure. The anterior transhepatic approach may have caused massive bleeding due to the presence of scarring from the previous hepatectomy. Therefore, we performed an isolated total caudate lobectomy, i.e., a "high dorsal resection" as a second hepatectomy. The postoperative course of the patient was uneventful, and there has been no local recurrence 1 year after the repeat hepatectomy. Indeed a "high dorsal resection" is rarely required, but it is still ingenious, and this surgical modality can balance the curability with the hepatic functional reserve even for recurrent caudate HCC in patients with liver cirrhosis.

Percutaneous Transhepatic Drainage of Inaccessible Abdominal Abscesses Following Abdominal Surgery Under Real-Time CT-Fluoroscopic Guidance

This study evaluated the safety, feasibility, and clinical utility of transhepatic drainage of inaccessible abdominal abscesses retrospectively under real-time computed tomographic (CT) guidance. For abdominal abscesses, 12 consecutive patients received percutaneous transhepatic drainage. Abscesses were considered inaccessible using the usual access route because they were surrounded by the liver and other organs. The maximum diameters of abscesses were 4.6-9.5 cm (mean, 6.7 +/- 1.4 cm). An 8-Fr catheter was advanced into the abscess cavity through the liver parenchyma using real-time CT fluoroscopic guidance. Safety, feasibility, procedure time, and clinical utility were evaluated. Drainage catheters were placed with no complications in abscess cavities through the liver parenchyma in all patients. The mean procedure time was 18.8 +/- 9.2 min (range, 12-41 min). All abscesses were drained. They shrank immediately after catheter placement. In conclusions, this transhepatic approach under real-time CT fluoroscopic guidance is a safe, feasible, and useful technique for use of drainage of inaccessible abdominal abscesses.

Left-sided gallbladder: a complicated percutaneous cholecystostomy and subsequent hepatic embolisation

A 68-year-old male patient with chronic hypertension, diabetes mellitus and chronic renal failure was diagnosed with acute calculous cholecystitis. A percutaneous cholecystostomy using a transperitoneal approach was performed after two failed attempts with a right-sided transhepatic approach. Subsequent hepatic embolisation was performed for the treatment of haemoperitoneum due to hepatic injury after the percutaneous cholecystostomy. The presence of a left-sided gallbladder was confirmed by laparoscopic cholecystectomy after 1 week. Prior identification of this anomaly would have prevented hepatic injury through the use of a cautious procedure against mobility or careful selection of the approach routes. In conclusion, the transperitoneal approach can be easier or more preferable to perform for a percutaneous cholecystostomy of a left-sided gallbladder.

Percutaneous Transcholecystic Placement of an ePTFE/FEP-Covered Stent in the Common Bile Duct

We report the case of a 78-year-old male patient with obstructive jaundice due to a pancreatic head neoplasm. The patient's general condition did not permit an endoscopic approach and the presence of diffuse liver metastases prohibited hepatic puncture for percutaneous biliary drainage, therefore the transcolecystic transperitoneal approach was decided to be the safest decompression route. Through a gallbladder access, a Viabil-covered stent with a mesh extension was placed in the distal common bile duct, without complications. The patient died 8 months later without signs of stent dysfunction or necessity of reintervention. Transcholecystic transperitoneal access is a safe option when diffuse liver metastases prohibit the transhepatic approach, even in cases where placement of a covered stent is considered necessary.

Chronic Portal Vein Thrombosis After Liver Transplantation in a Child Treated by a Combined Minimally Invasive Approach

Portal vein thrombosis (PVT) after orthotopic liver transplantation is an infrequent complication, and when it is present surgical treatment is considered for traditional management. Percutaneous transhepatic portal vein angioplasty has been described as an option to treat PVT with a lower morbidity than conventional surgical treatments. This article describes a case of chronic PVT in a child after a living donor liver transplantation managed by percutaneous transhepatic and surgical approaches.

Left ventricular assist via percutaneous transhepatic transseptal cannulation in swine

To report the in vivo testing of transhepatic, transseptal cannula insertion to support the left ventricle. Percutaneous cannulation for circulatory assist poses particular challenges in pediatrics. We utilized a strategy using a transhepatic, transseptal venous cannula inserted into the left atrium, a centrifugal pump, and arterial cannula. Yorkshire swine of 5-20 kg (n = 6) were anesthetized for the procedure. After hepatic venous angiography, percutaneous puncture of the hepatic vein was performed, followed by transseptal puncture with echocardiographic guidance. A 10-14 Fr 26-cm venous inflow cannula was placed in the left atrium via hepatic approach. The femoral artery was cannulated with a 6-10 Fr femoral cannula, and the circuit completed with the TandemHeart centrifugal pump. Implantation of the system utilizing the transhepatic approach was successful in all experiments. The pump delivered flows ranging from 0.8 to 1.4 L/min, which corresponded to 40-86% of the baseline systemic outputs. Decannulation and occlusion of the hepatic tract was successful utilizing transcatheter vascular occlusion plugs. The transhepatic, transseptal insertion of the inflow cannula, coupled with the TandemHeart centrifugal pump and femoral arterial cannulation allows percutaneous circulatory support in 5- to 20-kg models.

Long-Term Follow-up Study of Biliary Reconstructions and Complications After Adult Living Donor Liver Transplantation: Feasibility of Duct-to-Duct Reconstruction With a T-Tube Stent

The aim of this study was to analyze the feasibility of duct-to-duct biliary reconstruction (hepaticohepaticostomy) with a T-tube stent (HH-T) after adult living donor liver transplantation (LDLT) based on long-term follow-up. We retrospectively evaluated 63 primary adult LDLTs who had survived >1 month from March 1999 to January 2008. We compared the incidence of bile leaks and biliary strictures (BS) in 3 groups of patients: Roux-en-Y hepaticojejunostomy (HJ; n = 18); duct-to-duct hepaticohepaticostomy with external stents except a T-tube (HH; n = 26); and HH-T (n = 19). Median follow-up was longer among the HJ (63 months) than the other groups (32 months in HH and 25 months in HH-T; P = .04). Bile leaks developed in 8 of the HJ cases (44%); 9 of the HH cases (33%); and 1 of the HH-T cases (5%; P = .02). All cases with bile leaks (n = 18) were treated using continuous drainage, 15 of them (83%) successfully. BS developed in 4 HJ cases (22%); 12 HH cases (46%), and 4 HH-T cases (21%; P = .12). Intervention for BS (n = 20) was successful in 10 cases (50%) via an endoscopic approach and 6 cases (30%) via a percutaneous transhepatic approach. Operative management for BS was required in 4 cases (20%). Biliary reconstruction using HH-T may be effective to prevent bile leaks after LDLT. However, HH-T may not decrease the incidence of BS after adult LDLT.

Endovascular Diagnosis and Intervention in Patients with Isolated Hyperammonemia, with or without Ascites, after Liver Transplantation

Hyperammonemia with or without ascites with normal synthetic liver functions after liver transplantation might indicate the presence of anastomotic stenosis of the portal or hepatic vein or the existence of a patent portosystemic shunt. The authors describe six patients, three children after split-liver transplantation and three adults after cadaver liver transplantation, who presented with hyperammonemia. Three patients had ascites. All lesions were successfully treated percutaneously; stents were placed in patients with anastomotic stenoses and coil embolization was performed in patients with patent portosystemic shunts--with either transhepatic or transjugular approaches according to the site of the abnormality. Ammonia levels returned to normal, and ascites had regressed completely for at least 3 months.

Hypoplastic left heart syndrome with intact atrial septum: Utilization of a hybrid catheterization facility for cesarean section delivery and prompt neonatal intervention

Hypoplastic left heart syndrome (HLHS) with intact atrial septum (IAS) is a severe congenital cardiac malformation with little possibility of postnatal survival, unless an intra-atrial connection is created promptly after delivery. The timing of that intervention is often dictated by logistic restrictions, such as the proximity of the delivery room to the cardiac catheterization laboratory. This report details the use of a hybrid cardiac catheterization suite to expedite the delivery, transfer, and initial treatment of a fetus with HLHS/IAS. The mother underwent cesarean delivery in one hybrid room, and the newborn infant was transferred directly into an adjoining room where successful atrial septal stenting was performed without delay via a percutaneous, transhepatic approach.

Percutaneous ultrasound‐guided stenting of the atrial septum in fetal sheep

Hypoplastic left heart syndrome (HLHS) with a restricitive foramen ovale is associated with high mortality related to fetal left atrial hypertension. Fetal atrial balloon septoplasty has largely failed to achieve adequate decompression due to the small size of the holes produced. We attempted to produce larger atrial communications by stenting the atrial septum in fetal sheep using a minimally invasive technique. We used a percutaneous, ultrasound-guided transpulmonary or transhepatic approach to attempt deployment of coronary stents (2-5 mm in diameter and 13-23 mm in length) in the atrial septum primum of 10 normal fetal sheep. Coronary stents were deployed in eight of the 10 fetal sheep (119-139 days' gestation). The transhepatic route was unsuccessful (n = 2). Transpulmonary implantation was only possible in prone fetuses, so three initially supine fetuses underwent external version. Small coronary stents (2.0-2.5 mm in diameter) were deployed rapidly without complication via an 18G needle (n = 4). Larger coronary stents (5 mm in diameter) were delivered through a 4F sheath, but a right pleural effusion occurred in three of the four cases, related to inferior vena cava injury by the balloon. One stent dislodged from a floppy septum. Another was partially occluded within a week by endocardial cells. Percutaneous ultrasound-guided deployment of coronary stents into the septum primum is feasible without laparotomy or uterine exteriorization in fetal sheep. Partial luminal occlusion by rapid proliferation of endocardial cells is a concern.

Long-term Outcome of Percutaneous Transhepatic Therapy for Benign Bilioenteric Anastomotic Strictures

To evaluate the long-term outcomes of a percutaneous transhepatic approach in benign bilioenteric anastomoses with calibration of the stenosis to 15 F and extended internal/external drainage. Between February 2000 and May 2007, the efficacy of this percutaneous transhepatic procedure was retrospectively studied in 39 patients with benign postoperative bilioenteric anastomotic strictures. The main purpose of the protocol was to repair the anastomosis by calibration of the stenosis to 15 F with a silicone drain and perform internal/external drainage for at least 1 year. The follow-up period ranged from 12 to 65 months (mean, 34.4 months), and outcomes were classified according to the patient's clinical symptoms and laboratory parameters and the need for further interventions. The procedure was successful in 38 of 39 patients. Four patients were lost to follow-up during or after drainage. The duration of drainage (41 internal catheters in 34 patients) ranged from 126 days to 488 days (mean, 346 d). Twenty-seven patients had positive outcomes during the mean follow-up of 34 months, and six patients had negative outcomes. The bile duct patency probability according to the Kaplan-Meier method was and 70.6% at 34 months after drain removal. Percutaneous treatment of benign biliary strictures with calibrated stent implantation and extended drainage has good long-term results and may be an effective alternative to surgery. Advantages over surgery are its minimal invasiveness and reduced risk of complications.

Endoscopic transpapillary gallbladder drainage in patients with acute cholecystitis in whom percutaneous transhepatic approach is contraindicated or anatomically impossible (with video)

In patients with acute cholecystitis and at high risk for surgery, decompression of the gallbladder by percutaneous transhepatic gallbladder drainage (PTGBD) or aspiration (PTGBA) is needed as salvage therapy. However, we sometimes encounter patients in whom puncture cannot be performed for several reasons. Recently, endoscopic transpapillary gallbladder drainage (ETGD) has been reported to be safe and effective for acute cholecystitis. Our purpose was to evaluate the clinical efficacy and safety of ETGD for acute cholecystitis in which a percutaneous transhepatic approach is contraindicated or anatomically impossible. Retrospective case study. This procedure was performed in Tokyo Medical University Hospital. Forty-three patients with acute cholecystitis, including 32 patients taking anticoagulation or antiplatelet drugs, 4 cases of Chilaiditi syndrome, 2 each of acute leukemia, marked ascites, and anatomic abnormality, and 1 case of hemophilia A. All patients underwent ETGD. A 5F nasobiliary-drainage catheter was placed into the gallbladder. In case of failed ETGD, PTGBD or PTGBA was performed subsequently. Efficacy and safety of this technique. ETGD was achieved in 36 patients (84%) without any serious procedure-related complications. A clinically favorable response for ETGD was seen in 35 patients (97%). In 7 patients in whom ETGD was unsuccessful and 1 patient in which it was ineffective, a percutaneous transhepatic approach was performed with severe hemorrhage biloma in the former and uncontrolled hemorrhage cholecystitis, leading to death in the latter. Difficulty of maneuvering the guidewire and drainage tube into the gallbladder. Although comparative studies are needed to define the appropriate role of ETGD and percutaneous transhepatic approach, ETGD can be useful in patients with acute cholecystitis in which a percutaneous transhepatic approach is contraindicated or anatomically impossible.

Combined Pancreatic Islet-Lung Transplantation With Islet Percutaneous Portal Embolization in Cystic Fibrosis

Combined Pancreatic Islet-Lung Transplantation With Islet Percutaneous Portal Embolization in Cystic Fibrosis

Percutaneous Transhepatic Portal Vein Embolization: Rationale, Technique, and Outcomes

Portal vein embolization (PVE) is used to induce preoperative liver hypertrophy in patients with anticipated marginal future liver remnant (FLR) volumes who are otherwise potential candidates for resection. PVE can be performed utilizing the transhepatic contralateral and ipsilateral approaches. The transhepatic contralateral approach is the most commonly used technique worldwide, largely owing to its technical ease. However, the contralateral approach risks injuring the FLR, thereby compromising the planned surgical resection. The transhepatic ipsilateral approach offers a potentially safer alternative because the complications associated with this approach affect only the hepatic lobe that will be resected and are usually not serious enough to preclude surgery. This article discusses PVE using the transhepatic ipsilateral and contralateral approaches, including patient selection criteria, anatomical and technical considerations, and patient complications and outcomes.

Extensive hilar bile duct resection using a transhepatic approach for patients with hepatic hilar bile duct diseases

Background Extensive hilar bile duct resection beyond the second- or third-order intrahepatic biliary radicals is usually required for patients with hilar cholangiocarcinoma as well as those with benign inflammatory stricture. Most hilar cholangiocarcinoma is resected with combined major hepatectomy to obtain free surgical margins. The purpose of this study was to show the surgical procedure and the usefulness of extensive hilar bile duct resection using a transhepatic approach for patients with hilar bile duct diseases. Methods Five patients with hepatic hilar bile duct disease and who were unfit for major hepatectomy for several reasons underwent extensive hilar bile duct resection by way of a transhepatic approach. Four of the patients had hilar bile duct cancer, including 1 with mucous-producing bile duct cancer of low-grade malignancy and 1 with a postsurgical benign bile duct stricture. Results After extensive hilar bile duct resection, bile duct stumps ranged in number from 3 to 7 mm (mean 4.4). Surgical margins at bile duct stump were free of cancer in all 4 cancer patients. The long-term outcomes were as follows: 3 patients are alive at the time of publication, and 2 patients have died. Conclusions A transhepatic approach may be useful when performing extensive hilar bile duct resection bile duct stricture of biliary disease at the hepatic hilus, especially in high-risk patients who are unfit for major hepatectomy as well as in those having benign bile duct stricture and low-grade malignancy.

Transhepatic Techniques for Accessing the Biliary Tract

Gaining access to the biliary tract by minimal invasive image-guided techniques is the forefront procedure for interventionalists to manage biliary disease. The technical know how and learned maneuvers are the fundamental skill sets of an interventional radiologist. This article details the technical maneuvers that can be utilized to gain access to the biliary tract with a needle and/or catheter/wire combinations. These techniques include (1) fluoroscopic-guided needle localization from a percutaneous transhepatic approach, (2) different types of wire access/entry into the biliary system, (3) the use of intrabiliary snares as targets for secondary/additional biliary access, (4) recannulating transhepatic biliary tracts after inadvertent discontinuation of percutaneous biliary drains, and (5) ultrasound-guided left-sided biliary duct access.

Abstract No. 303: Percutaneous Retrograde Transjejunal Cholangiography and Biliary intervention for Beningn and Malignant Strictures

Abstract No. 303: Percutaneous Retrograde Transjejunal Cholangiography and Biliary intervention for Beningn and Malignant Strictures

Usefulness of the “Rendezvous” Technique in Living Related Right Liver Donors with Postoperative Biliary Leakage from Bile Duct Anastomosis

This is a report on two cases of large bile leak following right hepatectomy performed for living related liver transplantation, originating from the stump of the ligated right bile duct, and treated with the placement of large percutaneous biliary catheters through a combined percutaneous transhepatic and endoscopic approach (rendezvous technique).