|Year : 2021 | Volume
| Issue : 4 | Page : 260-265
Percutaneous biliary interventions
Usha Goenka1, Surabhi Jajodia1, Gajanan A Rodge2
1 Department of Clinical Imaging and Interventional Radiology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
2 Institute of Gastrosciences and Liver, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
|Date of Submission||29-Nov-2021|
|Date of Decision||02-Dec-2021|
|Date of Acceptance||04-Dec-2021|
|Date of Web Publication||23-Dec-2021|
Director and HOD, Department of Clinical Imaging and Interventional Radiology, Apollo Multispeciality Hospitals, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Biliary drainage is used to decompress bile duct, both in benign and malignant biliary strictures, to control cholangitis, pruritus, and increasing jaundice. This review is focused on analyzing the position of interventional radiology in the algorithm of management of biliary diseases in our daily practice. It gives a description of indications, techniques, safeness, effectiveness, and main risks involved in various percutaneous biliary procedures, while also providing useful and practical tips for clinical practice decisions.
Keywords: Biliary drainage, interventional radiology, percutaneous biliary interventions
|How to cite this article:|
Goenka U, Jajodia S, Rodge GA. Percutaneous biliary interventions. Apollo Med 2021;18:260-5
| Introduction|| |
Biliary drainage can be achieved by percutaneous techniques or by endoscopic methods (ERCP or EUS guided). Percutaneous biliary interventions have made a paradigm shift in management of biliary obstruction (both benign and malignant) and postsurgical biliary complications. A preoperative biliary drainage can be occasionally carried out, if significant liver resection is planned, surgery is delayed, or when neoadjuvant chemotherapy is planned. Studies have shown superior results with percutaneous drainage in advanced hilar obstructions. In most advanced malignancies, however, it is used as a palliative procedure. In this write-up, we will focus on the key aspects that have a significant bearing on the outcome.
The scope of percutaneous biliary interventions is mentioned in [Table 1]. The various indications for percutaneous biliary interventions are described in [Table 2].
| Technical Considerations and Basic Principles|| |
It is essential to have a recent high-resolution imaging, computed tomography, or magnetic resonance imaging, prior to planning of management, because it helps in evaluating extent of disease, whether resectable or unresectable, and allows assessing nature, whether benign or malignant, with an accuracy of magnetic resonance cholangiopancreatography (MRCP) for this being 90%. Imaging also helps look for evidence of parenchymal atrophy or lobes with portal vein thrombosis as draining these lobes/segments does not provide a functional benefit. An accurate delineation of obstructed ducts is done and a biliary road map is thus obtained. All this information helps in meticulous planning of intervention and in prognosticating the realistic outcome which should be conveyed to patient, relatives, and referral doctor.
Presence of ascites increases the technical difficulty in percutaneous interventions, and causes pericatheter leakage of ascitic fluid leading to skin excoriation and emotional stress to patient. Preprocedure paracentesis and use of left duct approach are possible solutions. Use of prophylactic antibiotics is an essential part of Society of Interventional Radiology Guidelines, as biliary interventions are considered as “clean contaminated” procedures (National Academy of Sciences). Biliary access is obtained at ultrasound/Doppler and fluoroscopy guidance.
| Percutaneous Transhepatic Cholecystostomy|| |
Various indications for percutaneous transhepatic cholecystostomy are calculous cholecystitis with high surgical risk due to comorbidities, acalculous cholecystitis, and transcholecystic biliary drainage, when intrahepatic biliary radicals (IHBRs) are not dilated. Small-caliber 7-8F pigtail catheter is left in situ for 2–3 weeks to allow the drain tract to mature. Complications such as pain, bleeding, and biliary peritonitis can occur in 5%–15% of patients. [Figure 1] shows percutaneous transhepatic cholecystostomy.
| Percutaneous Transhepatic Cholangiogram|| |
Percutaneous transhepatic cholangiogram (PTC) is done as the first step in all percutaneous biliary interventions. Initial puncture needle (18–22Gz) is passed into bile duct under ultrasound guidance and contrast is injected to obtain a cholangiogram. Type of biliary duct involvement determines the risk of cholangitis during drainage procedure. These can be (i) complete isolation, where the duct systems are completely segregated with no contrast seepage from one duct to another, (ii) effective isolation, where narrow ducts allow contrast to seep in but prevent adequate drainage, and (iii) impending isolation, where narrowed ducts are presently draining through the same catheter but may soon progress to effective isolation in the near future. The latter two are associated with increased risk of cholangitis and therefore require greater vigilance.
Due to advances in imaging like MRCP and EUS, its use as a diagnostic tool is obsolete, as PTC was associated with a high incidence of cholangitis despite all precautions. [Figure 2] shows a PTC with dilated bile duct and IHBR.
| Percutaneous Biliary Drainage and Stenting|| |
Untreated obstructive jaundice has poor outcomes both in terms of quality of life and survival. Hence, early decompression of an obstructed biliary tree, whether due to a benign or malignant etiology, is essential and is the mantra to success. The etiologies for obstructive jaundice are shown in [Table 3].
Percutaneous biliary drainage can be external drainage or internal–external drainage. In external biliary drainage, catheter is placed above the site of obstruction and bile drains into an external bag. Effective decompression is obtained, but discomfort due to catheter, fear of catheter dislodgement, and excessive bile loss leading to hypovolemia and electrolyte imbalance are limiting factors.
In internal–external biliary drainage, a ring biliary catheter is placed below the site of obstruction with multiple side holes lying both above and below the site of stricture, and bile drains both internally and externally. [Figure 3] shows the techniques of percutaneous transhepatic biliary drainage (PTBD). [Figure 3] shows the techniques of PTBD.
Stenting has both physical advantage and psychological advantage compared to catheter drainage. Stents can be plastic or metal (bare or covered). Covered stents can be easily removed or exchanged and is therefore commonly used for benign strictures. Biodegradable stents are a recent entrant, and do not require reintervention for removal. Stenting can be primary (PS) or staged (SS), results of latter being better. Multiple stents can be used in different configurations: “Y” or “T,” “stent in stent,” or “stent besides stent.” Balloon dilatation should be avoided, as it increases the incidence of bleeding and bacteremia. A safety catheter can be left for 24–48 h till stent expands fully. Access tract can be embolized at the end of procedure using Gelfoam pledgets. [Figure 4] shows the different stents used in for percutaneous biliary drainage and equipment required.
|Figure 4: (a) Different types of stents used in biliary drainage. (b) Equipments used for biliary drainage|
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| Benign Biliary Strictures|| |
Most benign biliary strictures result from prior biliary tract surgery. While endoscopic procedures such as balloon dilatation and stenting are preferred in low bile duct obstruction, percutaneous treatment is preferred in high choledocho-intestinal anastomotic strictures, altered anatomy after previous surgery, and in cases with difficult papillary access. Percutaneous techniques used are balloon dilation, drain placement, and/or stenting. Results of percutaneous treatment are good with short-term patency rate in primary stenosis being 90%–100% and long-term patency rate being 74%. The rate of restenosis is 30% and success in restenosis is 90%.
| Posttransplant Biliary Strictures|| |
Posttransplant biliary strictures occur in 15%–18% of patients, can be anastomotic or nonanastomotic, latter being due to tension at the surgical anastomosis, ischemia, or size mismatch between donor and recipient. MRCP has a high sensitivity for diagnosis, being 96% compared to 71% for ultrasound. Results are better for nonischemic strictures, with patency rate being 94%–100% at 1 year.
| Biliary Stone Disease|| |
ERCP is mostly the first line of management. Percutaneous method may be considered in cases with altered anatomy, difficult papillary access, or for intrahepatic ductal stones. Common bile duct (CBD) stones are usually pigment stones which are soft and easily macerated. Stones dropping down from gall bladder (GB) into CBD are harder as these are calcified cholesterol stones and are more difficult to manage. Percutaneous techniques used are balloon expulsion, stone basket, and/or laser lithotripsy. Success of percutaneous techniques for CBD stone is high (90%) but for intrahepatic stones is lower (60%). Multiple sessions may be needed. Complications can occur in 6%–7% and include cholangitis or subcapsular bilomas.
| Iatrogenic Bile Duct Injuries|| |
Bile duct injuries are serious complications of hepatobiliary surgery. Imaging and interventional radiology play an important role both in detection and treatment. While small leaks can be managed conservatively, larger leaks require biliary diversion in addition to drainage of bilomas. Intractable leaks, if present, may require sclerosis of the isolated duct using ethanol or glue cyanoacrylate).
| Malignant Biliary Strictures|| |
Treatment of malignant biliary stricture depends on resectability of the malignancy and percutaneous drainage and stenting provides a safe and effective palliative method of care in such patients. Surgery can be a “curative” option for resectable malignancies which involves aggressive tumor resection with or without preoperative biliary drainage and portal vein embolization. For unresectable tumors, palliation is the only treatment. More than 50% of functional liver should be drained, as this allows effective drainage with significantly decreased morbidity and increased median survival. Volumetry may be done to check effectiveness of drainage plan. If cholangitis is present, all ducts should be drained and it is important to remember that even a wire insertion can cause duct contamination and cholangitis. Treatment is decided on the basis of type and level of obstruction, on etiology of stricture, and on intent of drainage – whether preoperative or palliative. It also depends on the availability of expertise in the given center and on the life expectancy of the patient. The perihilar, distal, and intrahepatic cholangiocarcinomas differ in their presentation and natural history and the approach to treatment also varies in these cases.
Distal and Bismuth Type I/II strictures are mostly managed at endoscopy. Interventional radiologists are called as required for salvaging a failed endoscopic procedure or when ERCP is technically not feasible like in a proliferative growth obstructing the duodenal lumen or presence of a duodenal stent across papilla, preventing the ERCP scope from reaching the papilla. [Figure 5] shows a case with malignant obstruction and case of duodenal stent across papilla where PTBD was needed as ERCP was not feasible. [Figure 6] shows a case in which ERCP stenting was ineffective and salvaged by PTBD.
|Figure 5: Percutaneous biliary drainage in a case of malignant gastro-duodenal obstruction and duodenal stent across the papilla|
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|Figure 6: Type I stricture progressing to Type II: Unilateral endoscopic drainage became ineffective and salvaged by percutaneous stenting|
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Type III/IV strictures have complex ductal anatomy. Multiple catheters and stents are therefore required as insufficient drainage would lead to risk of cholangitis with poor results. At endoscopy, doing multi-duct drainage is a level 4 ASGE procedure which implies technically very challenging with high complication rate. Percutaneous approach in this situation is relatively easier and safer and, therefore, appears more rational., It is well substantiated in the literature that in Type III and Type IV strictures, PTBD is the preferred modality, as it has comparable results for risk of total complications, technical success rate and 30-day mortality rate, but is superior in terms of significantly lower risk of pancreatitis and cholangitis., [Figure 7] shows a Type IV stricture managed with multiple stents by primary PTBD approach.
|Figure 7: Type IV stricture: Managed by multiple stents and drains at “Primary” percutaneous procedure|
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The role of preoperative biliary drainage of the future liver remnant in resectable malignancy is controversial. One group states that doing a preoperative drainage improves liver function and decreases inflammation with resultant decrease in postoperative complications and improved overall outcomes. The other group has shown that preoperative biliary drainage worsens the outcome due to higher serious adverse events with resultant longer postoperative hospital stay. In addition, it is associated with an enhanced risk of tumor seeding. The indications for drainage are serum bilirubin >15 mg/dL, cholangitis, intractable pruritus, delay in surgery, and need for neoadjuvant chemotherapy. Endoscopic route is preferred for distal malignancy and percutaneous route is the preferred mode for perihilar advanced strictures. Here, external drains are preferred to external–internal drains or stenting.
| Intraluminal Palliative Treatment|| |
These include intrabiliary brachytherapy, photodynamic therapy, and radiofrequency ablation (RFA). Their use improves life expectancy and stent patency in malignant cases. These procedures are performed through PTBD access and are safe with a high success rate.
Active part of the probe is placed across stricture, output power of the RFA wave generator is adjusted to 10 W, and ablation is done for 1–2 min at each level along the length of stricture.
A photosensitizing agent is injected intravenously approximately 24–48 h before the procedure. A laser probe is placed at stricture site and it activates the agent to release oxygen-free radicles, which, in turn, kills the cancer cells.
| Percutaneous Transhepatic Intraluminal Tissue Biopsy|| |
It is done through biliary access and is performed prior to dilatation and stenting. Methods used are exfoliative cytology of bile aspirate, intraluminal brush biopsy, and intraluminal forceps biopsy, latter showing best results. Cholangioscopy improves the outcome and yield of procedure.
| Results and Complications of Biliary Procedures|| |
Results of percutaneous biliary drainage procedures are better than the acceptable threshold, both for “Success and Adverse events.” Major complications of procedures can occur in 3%–10% of patients and include cholangitis, sepsis, hemorrhage, and pleural transgression leading to hemo/pneumothorax and death. Transient bacteremia occurs in 1.8% despite prophylactic antibodies and present with chills, fever, tachycardia, and/or hypotension. Treatment is by intravenous fluids and antibiotics. Hemobilia occurs frequently but clears in 24 h. If persistent, it could indicate the presence of a side hole in portal/hepatic vein branch. Diagnosis is done on contrast study and treatment consists of repositioning/upsizing the catheter to provide tamponade. Pericatheter bleed in absence of hemobilia usually occurs due to hepatic artery injury and may manifest as pseudoaneurysm or arteriobiliary fistula. Treatment is by coil embolization.
EUS has added power in the hand of endoscopists by providing an alternate intraluminal route for performing biliary interventions, where ERCP has limitations. However, the complication rate in various reported series still remains high reaching up to 18%–29%, and it will be long before EUS expertise is universally available. Till then, interventional radiologists would be an integral part of the patient management team and continue to play a “major” role in biliary interventions.
| Conclusion|| |
Percutaneous procedures have a definite role as primary or nonsalvage techniques for biliary drainage. ERCP, EUS, and percutaneous techniques, however, need to be used judiciously and are best tailored to an individual by a multidisciplinary team approach.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3]