Management of post-surgical biliary leakage with percutaneous transhepatic biliary drainage (PTBD) and occlusion balloon (OB) in patients without dilatation of the biliary tree: preliminary results

Objective  

To compare the outcome of patients affected by biliary leak after major biliary surgery and treated with percutaneous transhepatic biliary drainage (PTBD) alone with that of similar patients treated with PTBD and concurrent positioning of an occlusion balloon (PTBD-OB).     

Newly Designed Y-configured Single-Catheter Stenting for the Treatment of Hilar-Type Nonanastomotic Biliary Strictures After Orthotopic Liver Transplantation

Purpose  

This study was designed to introduce our novel technique of percutaneous single catheter placement into the hilar bile ducts strictures while fulfilling the purpose of bilateral biliary drainage and stenting. We investigated the efficacy and safety of the technique for the treatment of hilar nonanastomotic biliary strictures.     

Percutaneous Intraductal Radiofrequency Ablation for Clearance of Occluded Metal Stent in Malignant Biliary Obstruction: Feasibility and Early Results

Purpose

The major complication occurring with biliary stents is stent occlusion, frequently seen because of tumour in-growth, epithelial hyperplasia, and sludge deposits, resulting in recurrent jaundice and cholangitis. We report a prospective study with the results of first in man percutaneous intraductal radiofrequency (RF) ablation to clear the blocked metal stents in patients with malignant biliary obstruction using a novel bipolar RF catheter.

Methods

Nine patients with malignant biliary obstruction and blocked metal stents were included. These patients underwent intraductal biliary RF ablation through the blocked metal stent following external biliary decompression with an internal–external biliary drainage.

Results

All nine patients had their stent patency restored successfully without the use of secondary stents. Following this intervention, there was no 30-day mortality, haemorrhage, bile duct perforation, bile leak, or pancreatitis. Of the nine patients, six are alive and three patients are dead with a median follow-up of 122 (range 50–488) days and a median stent patency of 102.5 (range 50–321) days. Six patients had their stent patent at the time of last follow-up or death. Three patients with stent blockage at 321, 290, and 65 days postprocedure underwent percutaneous transhepatic drain insertion and repeat ablation.

Conclusions

In this selective group of patients, it appears that this new approach is safe and feasible. Efficacy remains to be proven in future, randomized, prospective studies.     

British Society of Interventional Radiology: Biliary Drainage and Stenting Registry (BDSR)

Objectives  

This study was designed to audit current practice in percutaneous biliary drainage and stenting in the United Kingdom.     

Percutaneous management of biliary leaks: biliary embosclerosis and ablation

Biliary leaks after hepatobiliary surgery are not uncommon. In certain situations minimal invasive percutaneous techniques may result in avoidance or reduction of the extent of surgery. Minimal invasive percutaneous techniques include (1) percutaneous bile collection (biloma) drainage, (2) percutaneous transhepatic biliary drainage, (3) biliary leak site embolization/sclerosis, and (4) leaking biliary segment ablation. There are two clinical applications for biliary ablation. The first is actual bile leak site ablation or embosclerosis to reduce an aperture or ablate a fistula (block a hole). The second is ablating an entire biliary segment to cease bile production and induce hepatic segmental atrophy (cease bile production). This article discusses the techniques used for biliary leak site embosclerosis/ablation (including biliary-cutaneous tract ablation) and biliary segmental ablation.     

Percutaneous Intraductal Radiofrequency Ablation is a Safe Treatment for Malignant Biliary Obstruction: Feasibility and Early Results

Purpose

Previous clinical studies have shown the safety and efficacy of this novel radiofrequency ablation catheter when used for endoscopic palliative procedures. We report a retrospective study with the results of first in man percutaneous intraductal radiofrequency ablation in patients with malignant biliary obstruction.

Methods

Thirty-nine patients with inoperable malignant biliary obstruction were included. These patients underwent intraductal biliary radiofrequency ablation of their malignant biliary strictures following external biliary decompression with an internal-external biliary drainage. Following ablation, they had a metal stent inserted.

Results

Following this intervention, there were no 30-day mortality, hemorrhage, bile duct perforation, bile leak, or pancreatitis. Of the 39 patients, 28 are alive and 10 patients are dead with a median survival of 89.5 (range 14–260) days and median stent patency of 84.5 (range 14–260) days. One patient was lost to follow-up. All but one patient had their stent patent at the time of last follow-up or death. One patient with stent blockage at 42 days postprocedure underwent percutaneous transhepatic drain insertion and restenting. Among the patients who are alive (n = 28) the median stent patency was 92 (range 14–260) days, whereas the patients who died (n = 10) had a median stent patency of 62.5 (range 38–210) days.

Conclusions

In this group of patients, it appears that this new approach is feasible and safe. Efficacy remains to be proven in future, randomized, prospective studies.     

Percutaneous ultrasound-guided cholangiography using microbubbles to evaluate the dilated biliary tract: initial experience

Objective  

To evaluate the feasibility of percutaneous ultrasound cholangiography (PUSC) with a microbubble contrast agent in assessing obstructive bile duct diseases.     

Biliary leaks: treatment by means of percutaneous transhepatic biliary drainage

PURPOSE: To evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks. MATERIALS AND METHODS: Sixteen patients with a biliary leak involving either the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2) were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to severe acute necrotizing pancreatitis in six patients, while 10 patients had postoperative leak. Percutaneous transhepatic biliary drainage was performed with a 12-F catheter, with two series of side holes positioned on both sides of the extravasation to divert bile flow away from the defect. RESULTS: In 13 patients, the biliary leak healed after drainage (mean duration, 78 days). In four of these patients, a slight residual narrowing of the bile duct was treated by means of either balloon dilation (n = 2) or balloon dilation followed by insertion of a metallic stent (n = 2). All 13 patients remained cured (mean follow-up, 38 months). Two patients with severe acute necrotizing pancreatitis died of complications unrelated to the biliary leak. Vascular complications occurred in two patients, one of whom died after surgical drainage of a subcapsular hematoma. CONCLUSION: Biliary leaks can be treated successfully by means of percutaneous transhepatic biliary drainage. The procedure is particularly useful when surgical or endoscopic management has failed.     

Causes, clinical features and non-operative management of bile leaks

This paper evaluates the management of 31 patients with bile leaks identified over a 7-year period. Leaks complicated cholecystectomy in 19 patients (11 laparoscopic, 8 open), interventional procedures in 10 (including surgery in 1), trauma in one and was spontaneous in one case. Confirmation of the diagnosis typically lagged behind the onset of symptoms (mean for the group 4.2 days), indicating that a high index of suspicion is required in at-risk patients with typical symptoms. These include abdominal pain or distension, fever, bile leaking along a drain, jaundice, abnormal liver function tests and elevated white cell count. Two post-surgical bile leaks required surgical drainage of abdominal cellections. The remainder were successfully managed by non-operative methods including percutaneous drainage, endoscopic retrograde cholangiography with or without sphincterotomy or stent placement and percutaneous stenting. The spontaneous leak and all bile leaks complicating interventional procedures were managed non-operatively, although six patients in this group died due to the underlying malignant pathology. Only the patient with self-inflicted transection of the bile duct died directly from the complications of the bile leak. Although this is a varied, small series, we conclude that the majority of bile leaks can be managed by non-operative techniques. Whilst endoscopy is the primary modality for treatment, percutaneous techniques are crucially important for the management of complex cases and endoscopic failure. Received 3 September 1997; Revision received 2 February 1998; Accepted 20 March 1998     

Intra-biliary contrast-enhanced ultrasound for evaluating biliary obstruction during percutaneous transhepatic biliary drainage: A preliminary study

Objectives

The aimed of this study was to investigate the value of intra-biliary contrast-enhanced ultrasound (IB-CEUS) for evaluating biliary obstruction during percutaneous transhepatic biliary drainage (PTBD).

Materials and methods

80 patients with obstructive jaundice who underwent IB-CEUS during PTBD were enrolled. The diluted ultrasound contrast agent was injected via the drainage catheter to perform IB-CEUS. Both conventional ultrasound and IB-CEUS were used to detect the tips of the drainage catheters and to compare the detection rates of the tips. The obstructive level and degree of biliary tract were evaluated by IB-CEUS. Fluoroscopic cholangiography (FC) and computer tomography cholangiography (CTC) were taken as standard reference for comparison.

Results

Conventional ultrasound displayed only 43 tips (43/80, 53.8%) of the drainage catheters within the bile ducts while IB-CEUS identified all 80 tips (80/80, 100%) of the drainage catheters including 4 of them out of the bile duct (P < 0.001). IB-CEUS made correct diagnosis in 44 patients with intrahepatic and 36 patients with extrahepatic biliary obstructions. IB-CEUS accurately demonstrated complete obstruction in 56 patients and incomplete obstruction in 21 patients. There were 3 patients with incomplete obstruction misdiagnosed to be complete obstruction by IB-CEUS. The diagnostic accuracy of biliary obstruction degree was 96.3% (77/80).

Conclusion

IB-CEUS could improve the visualization of the drainage catheters and evaluate the biliary obstructive level and degree during PTBD. IB-CEUS may be the potential substitute to FC in the PTBD procedure.     

Percutaneous transhepatic biliary drainage (PTBD) with or without stenting��complications, re-stent rate and a new risk stratification score

Objectives  

To review the success rate and number of complications in patients with obstructive jaundice treated with percutaneous transhepatic biliary drainage (PTBD), and to stratify the procedural risk of both PTBD and biliary stenting.     

A new method of an axial puncture approach for draining loculated pleural effusions

Purpose  

The authors devised a new method of an axial puncture approach through the pulmonary apex (PA) for percutaneous catheter drainage (PCD) of loculated fluid collections extending to the PA. The purpose of this report is to introduce the new procedure.     

Outcomes of Salvage Percutaneous Biliary Drainage after Occlusion of Endoscopic Stents

Purpose

To describe outcomes of patients with malignant biliary obstruction who undergo salvage percutaneous biliary drainage after occlusion of endoscopic biliary stents.

Percutaneous management of complications of tuberculous spondylodiscitis: short- to medium-term results

Purpose

Psoas abscesses are the most frequent complication of tuberculosis with skeletal involvement. The aim of this paper is to report our experience with the systematic application of percutaneous drainage to tuberculous psoas abscesses.

Materials and methods

Between January 1997 and December 2005, 23 patients (14 men and nine women; age range 21–48 years), after a previous study with computed tomography (CT) and/or magnetic resonance (MR) imaging, underwent percutaneous drainage of a tuberculous fluid collection in the psoas muscles. Follow-up consisted of monthly clinical and laboratory assessment, and plain chest radiography and spinal CT every 6–12 months.

Results

Spondylodiscitis involved the thoracolumbar spine. Fluid collections were bilateral in 14 cases and communicating in ten of these. Maximum transverse diameter was 7 cm, whereas longitudinal diameter was 14 cm. Placement of the drainage catheter was successful in all cases, and the catheter was left in place for 5–36 (mean 18.4) days. Symptom regression occurred immediately after drainage of the fluid collection. The drainage procedure was curative in 100% of cases. Dislodgement of the drainage catheter occurred in two cases as a result of excessive traction during dressing removal.

Conclusions

A serious complication of bone tuberculosis, psoas abscesses, can be effectively treated by percutaneous drainage, leading to immediate pain resolution. The drainage catheter requires daily monitoring to identify when it can be safely removed without risk of recurrence.     

Image-guided percutaneous treatment of abdominal-pelvic abscesses: a 5-year experience

Purpose

This study was undertaken to evaluate the efficacy of image-guided percutaneous drainage in treating abdominal and pelvic abscesses.

Materials and methods

From August 2001 to August 2006, 95 patients (49 men and 46 women; mean age 61 years, range 25–92) with 107 abscesses underwent image-guided percutaneous drainage. Thirty-one abscesses were retroperitoneal (9 peripancreatic, 17 perirenal, 5 pararenal), 37 intraperitoneal (2 in communication with the small bowel), 8 intrahepatic (2 in communication with the extrahepatic biliary system and 2 with the intrahepatic biliary system), 4 perisplenic and 27 pelvic (4 in communication with the large bowel). Seventy-one of 107 procedures were performed with ultrasonographic (US) guidance and 36/107 with computed tomography (CT) guidance. All procedures were carried out with 8-to 14-Fr pigtail drainage catheters.

Results

Immediate technical success was achieved in 107/107 fluid collections. No major complications occurred. In 98/107 abscesses, we obtained progressive shrinkage of the collection (>50%) with consequent clinical success. In 9/107 cases, percutaneous drainage was unable to resolve the fluid collection. There were 12 cases of catheter displacement and six of obstruction.

Conclusions

Percutaneous drainage is feasible and effective in treating abdominal and pelvic abscesses. It may be considered both as a preparatory step for surgery and a valuable alternative to open surgery. Failure of the procedure does not, however, preclude a subsequent surgical operation.     

Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts

Percutaneous transhepatic biliary drainage (PTBD) have been described as an effective technique to obtain biliary access. Between January 1996 and December 2006, a total of 419 consecutive patients with endoscopically inaccessible bile ducts underwent PTBD. The current retrospective study evaluated success and complication rates of this invasive technique. PTBD was successful in 410/419 patients (97%). The success rate was equal in patients with dilated and nondilated bile ducts (p = 0.820). In 39/419 patients (9%) procedure related complications could be observed. Major complications occurred in 17/419 patients (4%). Patients with nondilated intrahepatic bile ducts had significantly higher complication rates compared to patients with dilated intrahepatic bile ducts (14.5% vs. 6.9%, respectively [p = 0.022]). Procedure related deaths were observed in 3 patients (0.7%). In conclusion, percutaneous transhepatic biliary drainage is an effective procedure in patients with dilated and nondilated intrahepatic bile ducts. However, patients with nondilated intrahepatic bile ducts showed a higher risk for procedure related complications.     

Percutaneous Treatment of Intrahepatic Biliary Leak: A Modified Occlusion Balloon Technique

Purpose

To report a novel modified occlusion balloon technique to treat biliary leaks.

Methods

A 22-year-old female patient underwent liver transplantation with biliary-enteric anastomosis. She developed thrombosis of the common hepatic artery and extensive ischemia in the left hepatic lobe. Resection of segments II and III was performed and a biliary-cutaneous leak originating at the resection plane was identified in the early postoperative period. Initial treatment with percutaneous transhepatic drainage was unsuccessful. Therefore, an angioplasty balloon was coaxially inserted within the biliary drain and positioned close to the leak.

Results

The fistula output abruptly decreased after the procedure and stopped on the 7th day. At the 3-week follow-up, cholangiography revealed complete resolution of the leakage.

Conclusion

This novel modified occlusion balloon technique was effective and safe. However, greater experience and more cases are necessary to validate the technique.

     

Bile Culture and Susceptibility Testing of Malignant Biliary Obstruction via PTBD

Purpose

To assess the information obtained by bile culture and susceptibility testing for malignant biliary obstruction by a retrospective one-center study.

Methods

A total of 694 patients with malignant biliary obstruction received percutaneous transhepatic biliary drainage during the period July 2003 to September 2010, and subsequently, bile specimens were collected during the procedure. Among the 694 patients, 485 were men and 209 were women, ranging in age from 38 to 78?years (mean age 62?years).

Results

A total of 42.9% patients had a positive bile culture (298 of 694). Further, 57 species of microorganisms and 342 strains were identified; gram-positive bacteria accounted for 50.9% (174 of 342) and gram-negative bacteria accounted for 41.5% (142 of 342) of these strains. No anaerobes were obtained by culture during this study. The most common microorganisms were Enterococcus faecalis (41 of 342, 11.9%), Escherichia coli (34 of 342, 9.9%), Klebsiella pneumoniae (28 of 342, 8.2%), Staphylococcus epidermidis (19 of 342, 5.5%), Enterococcus (18 of 342, 5.3%), and Enterobacter cloacae (16 of 342, 4.7%). The percentage of β-lactamase-producing gram-positive bacteria was 27.6% (48 of 174), and the percentage of gram-negative bacteria was 19.7% (28 of 142). The percentage of enzyme-producing Escherichia coli was 61.7% (21 of 34).

Conclusion

The bile cultures in malignant biliary obstruction are different from those in the Tokyo Guidelines and other benign biliary obstruction researches, which indicates that a different antibacterial therapy should be applied. Thus, knowledge of the antimicrobial susceptibility data could aid in the better use of antibiotics for the empirical therapy of biliary infection combined with malignant biliary obstruction.     

Interventional radiology in the gallbladder

This article is a pictorial review of the current status of interventional radiology of the gallbladder. The indications and technical aspects of various procedures are presented. Specifically discussed are: (1) needle puncture for percutaneous biopsy, withdrawal of bile for culture, or imaging of the biliary tract; (2) catheter insertion for decompression or abscess drainage; and (3) gallstone management via contact dissolution, fragmentation and basketing, or contact lithotripsy. The management of vagal hypotension and bile leak, the major complication of these procedures is also discussed.     

Detection of active bile leak with Gd-EOB-DTPA enhanced MR cholangiography: Comparison of 20–25 min delayed and 60–180 min delayed images

Objectives

The purpose of this study was to assess the value of contrast-enhanced magnetic resonance cholangiography (MRC) performed in different time delays after injection of gadoxetic acid disodium (Gd-EOB-DTPA) for the diagnosis of active bile leak.

Methods

This retrospective analysis included Gd-EOB-DTPA enhanced MR images of 34 patients suspected of bile leak. Images were acquired 20–25 min after Gd-EOB-DTPA injection. If there was inadequate contrast in the bile ducts then delayed images after 60–90 min and 150–180 min were obtained. Results were correlated with intraoperative findings, ERCP results, clinical data, laboratory tests, and follow-up examinations.

Results

Gd-EOB-DTPA enhanced MRC yielded an overall sensitivity of 96.4%, specificity of 100% and accuracy of 97.1% for the diagnosis of an active bile leak. The sensitivity of 20–25 min delayed MR images was 42.9%, of combined 20–25 min and 60–90 min delayed images was 92.9% and of combined 20–25 min, 60–90 min and 150–180 min delayed images was 96.4%.

Conclusions

Gd-EOB-DTPA enhanced MRC utilizing delayed phase images was effective for detecting the presence and location of active bile leaks. The images acquired 60–180 min post-injection enabled identification of bile leaks even in patients with a dilated biliary system or moderate liver dysfunction.