Transhepatic Catheter Research Articles

Surgical Treatment of Endocrine Pancreatic Lesions in Men-1

The surgical treatment of endocrine pancreatic lesion in the multiple endocrine neoplasia syndrome type 1 (MEN-1) has remained a controversial issue. Histologic studies have revealed that the pancreatic lesions generally consist of numerous microadenomas, spread throughout the pancreas, together with occasional larger tumors. The patients may also harbor multiple, mainly gastrin secreting, duodenal microadenomas. A total pancreatectomy/duodenectomy should theoretically be needed for cure, but has not been recommended due to the associated mortality and morbidity, considering also the favorable prognosis of most MEN-1 patients. When pancreatic involvement in MEN-1 is biochemically diagnosed efforts should be made to localize the lesions by computed tomography, angiography and, in some patients, also transhepatic portal vein catheterization and venous sampling (PTP). Hypergastrinemia and the Zollinger-Ellison syndrome (ZES) generally constitute two-thirds of the clinically detected pancreatic lesions in MEN-1. Surgery may be undertaken in ZES-MEN-1 patients with focal lesions visualized by radiology or PTP in order to minimize the risk of malignant development in a gross tumor. Patients with insulin excess and hypoglucemia as well as the rare vipoma patient may, even in the absence of radiologically visualized tumors, be subjected to exploration, and these patients are usually found to harbor one or several gross tumors. The more frequent clinically silent, mainly PP-producing tumors should be removed when visualized by radiology. However, indications for surgery also have to emphasize an unusually malignant behavior in certain kindreds and patients may thus have to be explored when only biochemical data indicate the presence of pancreatic lesions. Pancreatic operations in MEN-1 should generally include a corpus and tail resection, together with enucleation of lesions in the pancreatic head, and in addition to that a careful duodenal exploration. Intraoperative ultrasound examination appears to be of considerable value by its ability to reveal also smaller lesions which may escape palpation.

Maligner Stauungsikterus: Dekompression über externe biliogastrale Fistel

In cases of malignant bile duct obstruction in which internal biliary drainage cannot be established by surgical intervention or by implantation of a stent, the externally drained bile can be recycled by connecting the transhepatic catheter to a percutaneous gastrostomy. Experiences on three patients treated by the above method are reported.

Endoscopic retrograde cannulation of the gallbladder: direct dissolution of gallstones

Percutaneous transhepatic catheterization of the gallbladder for dissolution of cholesterol stones by instillation of methyl tert-butyl ether (MTBE) is an invasive therapeutic procedure. The only non-invasive alternative available to now, endoscopic retrograde cannulation of the cystic duct, was difficult because of the cystic duct's tortuosity and spiral valves. We therefore developed a catheter system which, using conventional duodenoscopes during a routine endoscopic retrograde cholangiography (ERC) procedure, permits reliable and safe catheterization of the gallbladder without the need for endoscopic sphincterotomy. In 18 of 22 patients (82%) we were able to place a cysto-nasal catheter, and in 14 patients MTBE dissolution therapy was then performed. Eight patients (57%) were completely free of stones after treatment; the other six (43%) had residual debris. In 4 of 22 patients (18%) cannulation attempts failed, in 3 patients due to cystic duct blockage by a calculus. Endoscopic retrograde cannulation of the gallbladder (ERCG) represents a promising alternative to the invasive percutaneous transhepatic catheterization procedure.

Hemobilia complicating transhepatic catheter drainage in liver transplant recipients: Management with selective embolization

Two liver transplantation patients are reported who experienced severe hemobilia following percutaneous placement of a transhepatic biliary drainage catheter. In both, hepatic angiography demonstrated the source of bleeding from a traumatic pseudoaneurysm of a right hepatic artery branch. Hemobilia in both patients was successfully treated using selective embolization techniques. Follow-up computed tomography of the liver showed no evidence of allograft necrosis or abscess formation. One patient developed an intrahepatic biliary stricture adjacent to the embolized branch artery nine months following the procedure. Hepatic artery embolization techniques are effective in the treatment of life-threatening hemobilia posttransplantation.

Gallstone Dissolution In Vitro Using Methyl tert-Butyl Ether: Radiologic Selection Criteria

Methyl tert-butyl ether dissolves cholesterol gallbladder stones when infused through a percutaneous transhepatic catheter. All gallstones, however, contain noncholesterol components that are insoluble in lipid solvents and may be too large to be aspirated through a small catheter or flushed from the gallbladder. To identify which patients have gallstones that are most likely to completely dissolve, we evaluated the ability of methyl tert-butyl ether to dissolve gallstones in vitro based on their radiodensity and size. Radiodensity influenced completeness of dissolution (p less than 0.01), but size did not (p greater than 0.5). Twenty-six of 32 radiolucent stones (81%) dissolved completely, leaving residual debris less than 2 mm in diameter. Only 2 of 32 radiopaque stones (6%) dissolved completely. Insoluble radiolucent and radiopaque stones less than 0.5 cm in diameter were black pigment stones. Four radiolucent and 19 of 22 radiopaque stones (86%) greater than 0.5 cm in diameter underwent partial dissolution leaving residual debris 2 mm or larger. By infrared spectroscopy, calcium bilirubinate and calcium carbonate were identified as the principal components of this methyl tert-butyl ether-insoluble debris. Until methods for dissolving or fragmenting noncholesterol components of gallstones are available, only patients with radiolucent gallstones should be treated with methyl tert-butyl ether.

Gastrinomas: localization by means of selective intraarterial injection of secretin.

Small doses (30 U) of secretin were injected directly into the splenic, gastroduodenal, hepatic, and superior mesenteric arteries of 13 patients with Zollinger-Ellison syndrome who were undergoing angiography to localize gastrin-secreting tumors of the islet cells. Blood samples from the right hepatic vein and a peripheral vein were drawn before and 30, 60, 120, and 210 seconds after each intraarterial secretin (IAS) injection. A 50% rise in gastrin level in the 30-second sample from the hepatic vein localized the gastrinoma to the head, body, or tail of the pancreas, depending on the artery into which secretion was injected. IAS results were positive in seven of 13 patients (54%); selective angiography was positive in five of 13 (38%); and the combined study, selective angiography with IAS injection, was positive in 10 of 13 (77%). Portal venous sampling was positive in six of 13 (46%). Selective IAS injection, combined with angiography, is the most sensitive study for localizing gastrinomas and avoids percutaneous transhepatic catheterization for portal venous sampling.

Percutaneous Dissolution of Gallstones using Methyl Tert-Butyl Ether

Radiolucent cholesterol gallstones can be dissolved rapidly by methyl terc-buryl ether (MTBE) introduced directly into the gallbladder. Percutaneous transhepatic catheter placement is a well established interventional radiology procedure and is the preferred route for MTBE administration. A small number of patients have been treated using nasobiliary placement of a gallbladder catheter. Rapid stirring automatic pump systems allow dissolution of most cholesterol stones, but some may require extracorporeal shock wave lithotripsy to achieve complete dissolution and aspiration of debris. Large bore percutaneous fragmentation and extraction methods require general anesthesia but are applicable to pigment stones.

Beeinflußt Domperidon die Hämodynamik von Ösophagusvarizen?

In three patients with portal venous hypertension and oesophageal varices the effect of domperidone on the haemodynamics of the varices was studied. Following transhepatic catheterisation of the left gastric vein the perfusion of the oesophageal varices before and after the application of domperidone was evaluated angiographically. No decrease of the perfusion of the oesophageal varices secondary to domperidone was observed using this method.

Dissolution of cholesterol gallbladder stones by methyl tert-butyl ether administered by percutaneous transhepatic catheter.

We treated 75 patients with symptomatic cholesterol gallstones by dissolving the stones with methyl tert-butyl ether (MTBE) instilled into the gallbladder through a percutaneous transhepatic catheter. The MTBE was continuously infused and aspirated manually four to six times a minute, for an average of five hours per day for one to three days; the treatment was monitored by fluoroscopy. The placement of the catheter and the administration of MTBE caused few side effects or complications, and treatment did not have to be stopped in any patient for this reason. In 72 patients there was complete dissolution of stones or more than 95 percent dissolution. Among 21 patients who were completely free of stones after treatment, 4 had recurrence of stone formation 6 to 16 months later. The other 51 patients had residual debris, which spontaneously cleared completely in 15 patients within 6 to 35 months; only 7 with persisting debris have had symptoms. Five of the initial 6 patients treated, but only 1 of the next 69 patients, have required surgery during follow-up periods of 6 to 42 months. We conclude that the dissolution of gallstones by MTBE delivered through a percutaneous transhepatic catheter is a useful alternative to surgery in selected patients with symptomatic cholesterol stones. Further study will be necessary to establish the long-term effectiveness of this treatment and its appropriate role in the management of the various types of gallstones.

Measurement of human portal blood flow by continuous thermodilution

We wanted to use the Ganz thermistor catheter, developed to measure blood flow in human coronary sinuses, to measure portal venous flow, which is greater. We prepared a model circuit with a high flow rate and studied the method for suitability and reproducibility of the measurements. Correlation was close between the measured and calculated flow rates when the thermal indicator was injected at the rate of 48 ml/min. Measurements were highly reproducible. The catheter was then tested clinically. It was inserted into the portal trunk during percutaneous transhepatic catheterization to measure the portal venous flow. Measurements in patients with cirrhosis of the liver were close to those reported by other workers, and were reproducible. The results suggest that this method will be useful for the continuous local measurement of portal venous flow that varies with time, and will provide information about portal circulation in hepatic disease.

Budd-Chiari syndrome: treatment with percutaneous transhepatic recanalization and dilation.

The authors describe a child with Budd-Chiari syndrome secondary to membranous obstruction of the hepatic veins and a web in the inferior vena cava. Transhepatic catheter venography demonstrated the occlusion, which was recanalized and dilated percutaneously via a transhepatic approach. Hepatomegaly and ascites decreased promptly and the prothrombin time became normal.

Biliary duct stones: update on 54 cases after percutaneous transhepatic removal.

Percutaneous transhepatic removal of common bile duct stones was performed 54 times in 50 patients with a success rate of 93%. In all patients, a modified Dormia basket was inserted through a percutaneous transhepatic catheter, and the stones or fragments were advanced into the duodenum. All patients had contraindications to surgery or had undergone unsuccessful attempts at endoscopic retrograde cholangiopancreatography and sphincterotomy. Monooctanoin (25 patients) or methyl tertiary-butyl ether (four patients) was infused to reduce stone size or remove residual debris. The average time for complete stone removal was 8.6 days. Morbidity was 13% and mortality was 4%, results which compare favorably with those of surgery.

Septic shock after percutaneous transhepatic drainage of obstructed afferent loop: Case report

For management of the afferent loop syndrome, surgical revision such as jejunojejunostomy or Roux-en-Y conversion is the established procedure. Percutaneous transhepatic catheter drainage was used as a method of palliative treatment of the obstructed afferent loop in a patient with extensive mesenteric and peritoneal dissemination of gastric cancer. There were no procedural-related complications, but severe bacterial cholangitis and septicemia occurred later. Our limited experience indicates that this procedure may be risky, and that an additional drainage catheter of the bile duct may be needed when biliary stasis is present.

The use of lasers in the treatment of cholangiocarcinoma

Six of seven patients were treated with external beam radiation, iridium-192 internal radiation and neodymium-YAG laser therapy via a percutaneous transhepatic tract for relief of biliary obstruction. After laser therapy, the transhepatic catheters were removed and patients remained tube-free and non-jaundiced for periods ranging from 1 to 20 months.

A New Hemostatic Procedure for Percutaneous Transhepatic Portal Vein Catheterization

To avoid major complications, such as intraperitoneal bleeding after percutaneous transhepatic catheterization, a new technique has been developed. In this procedure, a stick-like gelfoam sponge compressed manually and loaded in a cartridge, is inserted through an outer sheath catheter after the removal of the catheter, and the puncture hole is plugged. No bleeding has been experienced in 56 patients with various hepatic diseases since using this method.

Major liver resection for hilar cholangiocarcinoma.

Between 1968 and 1984 liver resection with curative attempt was performed in 22 patients with hilar cholangiocarcinoma. Right lobectomy was performed in 4 patients, extended right lobectomy in 7, left lobectomy in 8, and excision of the median segment segment of the left lobe (segment IV) in 3. Bilio-enteric continuity was restored by hepatocholedochostomy in 17 patients and hepatojejunostomy in 4. (One patient had external transhepatic catheter drainage and no internal bile drainage.) Operative mortality rate was 27% and caused by excessive intraoperative bleeding, sepsis, or liver insufficiency. Postoperative complications occurred in 57% of patients surviving the operation and were due mainly to leakage from the hepatocholedochostomy. Median survival was 6 months, and one third of the patients survived 1 year. Three patients survived 10 years and were among the four patients in whom a tumor-free resection margin was obtained (one of them died in the postoperative phase). It is concluded that resection of hilar cholangiocarcinoma may give long-term survival if a free resection margin is obtained. The importance of a free resection margin indicates that surgery should be aggressive and include liver resection.

Percutaneous transhepatic catheterization of the portal venous system

AbstractDuring recent years, percutaneous transhepatic catheterization of the portal venous system has become the most accurate procedure for investigation of the portal system. The procedure can be performed under local analgesia, is relatively simple, and complications are rare. The success rate is high, approximately 90%, especially when the liver hilum is localized by ultrasonography prior to catheterization. The free portal pressure can be measured. Selective catheterization of all portal tributaries can be performed. The indications are: portography in patients with cirrhosis of the liver and portal hypertension for delineation of collateral vein systems including gastro‐oesophageal varices; visualization of veins that may be used for portosystemic shunt operations; postoperative control of shunt patency; diagnosis of portal and hepatic vein thrombosis; localization of stenosis in the portal vein system; pre‐operative evaluation of patients with tumours in the biliary tract and pancreas; obliteration of bleeding oesophageal varices; and verification and localization of endocrine pancreatic tumours making curative resection possible. Further, transhepatic catheterization of the portal system may be used in research on the development of portal hypertension, collateral veins, variceal bleeding, and for haemodynamic, metabolic and pharmacologic studies in the gastrointestinal tract.

Refractory afferent loop problems: percutaneous transhepatic management of two cases.

Complications of the afferent loop are traditionally managed only by surgical revision. Transhepatic biliary drainage was used in the palliative treatment of two different afferent loop problems in critically ill patients for whom surgery was unsuccessful. Transcholecystic cholangiography was used to opacify the nondilated bile ducts and proved valuable for the transhepatic biliary catheterization procedure. There were no complications, and both patients showed clinical improvement.

Percutaneous transhepatic electrohydraulic lithotripsy under endoscopic control

With endoscopic papillotomy, extraction of bile duct stones has become a routine procedure. However, removal of large common bile duct stones or intrahepatic stones remains a difficult problem. To overcome this problem, several nonsurgical methods have been developed. Techniques of dissolution! by transhepatic catheter or nasobiliary drain are useful, but these require a relatively long period of treatment and have only moderate success. Lithotripsy in a retrograde manner employing a Nd:YAG laser or an electric spark,4 have proved to be very efficient, but choledoscopic control is compulsory and despite the development of several cholangioscopes, therapeutic retrograde choledoscopy still remains very difficult to perform. Lithotripsy using ultrasound is still experimental since bile ducts cannot be approached with a straight probe. Mechanical endoscopic lithotripsy requires the stone to be captured within a basket, and then some stones are too hard to be smashed in this way.6,? The development of percutaneous access to the kidney and the availability of the electrohydraulic or ultrasonic lithotripter have been combined to permit removal of renal and ureteral stones on a routine basis.s This combination has not been widely employed for bile duct stones. Recently, the use of percutaneous transhepatic electrohydraulic lithotripsy has been reported. The main problem with this technique is holding the electrode close to the calculus. We report a technique using percutaneous access, endoscopic control of the position of the lithotripter, and electrohydraulic lithotripsy.

Intraluminal radiation therapy for biliary tract malignancy—an endoscopic approach

Carcinomas involving the biliary tract commonly lead to biliary tract obstruction. Most tumors are unresectable at the time of diagnosis, and palliative surgery for biliary decompression is associated with a mortality rate of 10% to 15% and a morbidity rate of 25% to 35%.1,2 Radiation therapy has been used for treating carcinoma involving the biliary tract with variable success.5 More recently, effective palliation has been accomplished by percutaneously or endoscopically placed biliary stents or prostheses. Intraluminal radiation therapy (ILRT) has been used to deliver radiation to the tumor site at several centers. However, to accomplish such intraluminal radiation therapy, an indwelling T-tube or percutaneously placed transhepatic catheter is necessary. We report a new technique for intraluminal hepatobiliary radiation therapy using an endoscopically placed nasobiliary catheter as the port for introducing the radiation source. This technique has a unique advantage of avoiding percutaneous puncture for placement of a catheter into the liver or a laparotomy for T -tube placement.