Associate Professor of Radiology. Hospital of the University of Pennsylvania. Philadelphia, Pennsylvania. B ILIARY tract disease is one of the most common ...
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INTERVENTIONAL RADIOLOGY OF THE BILIARY TRACT* ERNEST J. RING, M.D. Associate Professor of Radiology Hospital of the University of Pennsylvania Philadelphia, Pennsylvania
B ILIARY tract disease is one of the most common indications for abdominal surgery, and cholecystectomy is performed approximately 500,000 times yearly in the United States. Carcinoma of the pancreas is now the second most common gastrointestinal malignancy and often necessitates surgical decompression of the biliary tree. Primary tumors of the common bile duct tend to metastasize late, and have been palliated for long peiods with the use of surgically implanted indwelling tubes. Obstruction of biliary radicals at the porta hepatis by metastatic cancer is a common terminal complication in patients with a variety of primary neoplasms and has never been thought to be amenable to surgery. A radiologist is in a unique position to assist in the management of many of these clinical problems. Percutaneous access into the biliary tree can be achieved either through surgically created drainage tracts or directly, through transhepatic approaches. Catheters can be introduced in this fashion and directed under direct fluoroscopic guidance throughout the intra and extrahepatic biliary tree to provide nonoperative solutions for many clinical conditions. In addition, even when surgery is to be performed, preliminary instrumentation by a radiologist can greatly facilitate subsequent operative procedures. This report reviews the applications of the various interventional radiologic procedures currently used in the management of patients with biliary tract disease.
INTERVENTIONS THROUGH SURGICALLY CREATED DRAINAGE TRACTS Nonoperative removal of retained common bile duct stones. It has been estimated that retained common bile duct stones occur in 5,000 patients annually.1 Various techniques have been developed to remove. these stones * Presented at a meeting of the Section on Radiology of the New York Academy of Medicine with the New York Roentgen Society February 25, 1980. Address for reprint requests: Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104.
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through surgical drainage tracts, and they have met with considerable success. Several large series have documented the efficacy and safety of this approach in the management of several hundred patients.`24 Reoperation for stone extraction is now required in only about 10% of cases.' Stone extraction is relatively painless and is performed as an outpatient procedure in many centers. Pancreatitis and sepsis have been reported as complications but these are exceedingly rare.2 Mazzariello3 has had considerable success using an extraction forceps, which he introduces through the drainage tract, but other investigators have more commonly advocated the use of a dormia type basket through a modified angiographic catheter.2'4 We have recently removed a retained common bile duct stone in a patient who had no drainage tract for access.5 The transhepatic approach was used to introduce a catheter into the common bile duct. A basket was placed through the transhepatic catheter, the stone was trapped in the basket and advanced into the duodenum where it was released. The safety of removing stones in this fashion is as yet unproven, and the procedure at present is limited to those patients who would be very high risk for reoperation. Once a stone has been removed through a transhepatic approach, the catheter can be left in place to decompress the biliary tree. T-tube disimpaction. Chronic intubation of the common bile duct is being used with increasing frequency by biliary surgeons to palliate obstructing malignancies or stent complicated benign strictures. The tubes may be T, Y, or U shaped, depending on variations in patient anatomy. Satisfactory palliation depends on prolonged maintenance of luminal patency. This is limited, however, since bile tends to form deposits of sludge which eventually will obstruct any type of tubing. Various irrigants have been used to attempt clearing of obstructed tubes but have met with little success. Open surgical replacement may necessitate multiple reoperations. Angiographic catheters can be passed easily through the lumen of any standard rubber tube 14F or greater. The catheter can be guided through each limb of the tube. Guidewires passed through the angiographic catheters can be used to fragment the sludged material which has a mudlike consistency. The resulting debris is then easily cleared with gentle irrigation and suction through the angiographic catheter.6 The procedure is painless and can be performed on an outpatient basis. We have recommended an aggressive maintenance program with prophylactic tube disimpaction every three to four months. This appears to be preferable to waiting until clinical symptoms of obstruction cholangitis have developed since these will eventually lead to deterioration of hepatic function. Bull. N.Y. Acad. Med.
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T-tube replacement. A technique was recently described which allows for nonoperative replacement of standard T-tubes through the originally created surgically drainage tract.7 The new tube can be positioned under fluoroscopic control so that its limbs are secured within the common bile duct. Using this approach, we have successfully replaced T-tubes in 32 consecutive attempts.8 These tubes were replaced for a variety of clinical indications, including "deterioration of permanently implanted tubes, inadvertent withdrawal or migration of tubes, extension of tumor to obstruct the common duct above or below a malignancy, and following nonoperative basket retrieval of stone. "
INTERVENTIONAL TECHNIQUES THROUGH A DIRECT TRANSHEPATIC APPROACH Several recent reports have documented the feasibility of introducing catheters transhepatically into an obstructed biliary tree.9"l0 These catheters can be manipulated within the biliary tree and in the vast majority of cases can be advanced across obstructing lesions. We have performed this procedure on 91 patients, and have successfully advanced the catheter through the obstruction into the duodenum in all but three cases. Once the transhepatic catheter has been advanced through the obstruction it can be replaced with a catheter that contains multiple sideholes positioned above and below the obstructing lesion. If the external portion of the catheter is then closed, bile will flow through the catheter into the duodenum. When patients have high obstructions near the liver edge, surgical decompression may be difficult. This is particularly true for metastatic lesions involving the lymph nodes surrounding the porta hepatis. These lesions have previously not been considered to be amenable to surgical decompression. The transhepatic catheter can be successfully utilized to palliate obstructive jaundice in this setting (29 patients). When the high obstruction is caused by a primary ductal tumor, the prognosis is relatively good if decompression can be achieved. A variety of tubes have been implanted surgically for this purpose.""2 Using a transhepatic approach, multiple catheters can be introduced to decompress the entire biliary tree even when the obstruction involves the intrahepatic branches. Palliative surgery for pancreatic carcinoma results in an operative mortality rate of 16 to 59%, and provides a mean survival time of only five to six months. 1:16 The transhepatic catheter can be introduced with a relatively low morbidity and mortality and serves to adequately relieve the biliary obstrucVol. 56, No. 6, July-August 1980
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tion. We have found this procedure useful for patients with pancreatic carcinoma in three settings: 1) Patients who were previously operated on and developed recurrent tumor which obstructed the common bile duct 2) Patients who are shown to be unresectable either by computerized tomography or angiography and have a diagnosis of carcinoma confirmed with a thin needle biopsy 3) Patients who are potentially operable but present with very high bilirubin levels. It has been shown that the operative mortality for pancreaticoduodenectomy is double when the bilirubin is greater than 20 mg%. In several centers now the resection is attempted in two stages. An initial drainage procedure such as a cholecystostomy is performed first, followed by resection when the bilirubin levels return to normal.17 Strictures. Approximately 95% of strictures of the common bile duct are related to previous surgery.8 Surgical correction of strictures provides good results in approximately 60% of cases.1 Transhepatic catheterization may be used to decompress the obstructed biliary tree and relieve symptoms until any infection has cleared, and may improve the surgical outlook considerably. Preliminary results recently reported by Melnar'9 and our own experience suggests that dilatation with balloon catheters may adequately enlarge strictures to provide an alternate form of management for these lesions.
COMPLICATIONS OF TRANSHEPATIC CATHETERIZATION
Complications follow transhepatic catheterization in about 14% of cases (91 patients-sepsis, nine; catheter came out, two; pneumothorax, 2; hemothorax, 1; bile peritonitis, 1). Bilious pleural effusion has not been a complication in our series but has been previously reported. Major bleeding from the liver may also occur. Hemobilia may occur when the sideholes in the catheter are positioned within the hepatic parenchyma. This complication is relieved by replacing the catheter with a new one containing fewer proximal sideholes. Sepsis is the most significant and life-threatening complication. Antibiotic coverage is instituted 24 hours before beginning the procedure, and maintained for at least two to three days after the catheter has been introduced. Despite this, bacteremia occurred in nine patients following the procedure. Four of these patients were profoundly septic before attempting catheter drainage with bacteremias and intra or extrahepatic abscesses secondary to either obstruction or previous surgery. Despite adequate bile drainage in Bull. N.Y. Acad. Mod.
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these cases, the clinical conditions did not improve. In the other five patients transient episodes of sepsis were successfully managed with fluid replacement and antibiotics. GENERAL PRINCIPLES FOR LONG TERM MAINTENANCE OF TRANSHEPATIC CATHETERS
Catheters of various sizes and materials have been introduced transhepatically. We have been using an 8.3 F catheter, which has an inner diameter of 1. 8 mm. This catheter has a pigtail tip configuration, which anchors in the duodenum to prevent inadvertent withdrawal. Multiple sideholes are created in the catheter and positioned above and below the obstruction. The external catheter is clamped and the patient is instructed to irrigate with sterile saline every two to three days. Routine replacement of the catheter over a guidewire every three months assures indefinite patency. Using this approach we have catheters functioning for two years. Pereirras has reported his experience introducing short indwelling stents which bridge the obstruction in 12 patients.1' We have utilized this same type of stent in two cases, but we feel that the advantage of being able to clear and replace the tubes far outweighs the disadvantage of maintaining the external portion of the catheter. The long-term patency of permanently indwelling stents will need to be compared with the success of external catheter maintenance. REFERENCES
1. Bartlett, M. K., Warshaw, A. L., and Ottinger, L. W.: The removal of biliary duct stones. S. Clin. N. Am. 54:599611, 1974. 2. Caprini, J. A., Crampton, A. R., and Swan, V. M.: Nonoperative extraction of retained common duct stones. Arch. Surg. 111:445-51, 1976. 3. Mazzariello, R. M.: Residual biliary tract stones: Nonoperative treatment of 570 patients. Surg. Ann. 8:113-44, 1976. 4. Bean, W. J., Smith, S. L., and Calonje, M.: T-tube dilatation for removal of large biliary duct stones. Radiology 115:485-86, 1975. 5. Perez, M. R., Oleaga, J. A., Freiman, D. B., et al.: Removal of a distal common bile duct stone through percutane-
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ous transhepatic catheterization. Arch. Surg. In press. Margulis, A. R., Newton, T. H., and Najarian, J. S.: Removal of plug from T-tube by fluoroscopically controlled catheter. Am. J. Roentgenol. 93:975, 1965. Crummy, A. B. and Turnipseed, W. D.: Percutaneous replacement of a biliary Ttube. Am. J. Roentgenol. 128:869-70, 1977. Ring, E. J., Freiman, D. B., Oleaga, J. A., et al.: Clinical applications of nonoperative T-tube replacement. Surg. Gynecol. Obstet. In press. Molnar, W. and Stockum, A. E.: Relief of obstructive jaundice through percutaneous transhepatic catheter-A new therapeutic method. Am. J. Roentgenol.
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122:356-67, 1974. Tidrick, R. T.: Bypass operations for neoplastic biliary tract obstruction. Am. 10. Mori, K., Misumi, A., Sugiyama, M., et al.: Percutaneous transhepatic bile J. Surg. 109:100-06, 1965. drainage. Ann. Surg. 185:111-15, 16. Hertzberg, J.: Pancreatico-duodenal resection and by-pass operation in patients 1977. with carcinoma of the head of the pan11. Stone, R. M., Cohen, Z., Taylor, B. R., et al.: Bile duct injury. Results of creas, ampulla, and distal end of the repair using a changeable stent. Am. J. common duct. Acta Chir. Scand. 140:523-27, 1974. Surg, 125:253-56, 1973. 12. Smith, R.: Hepaticojejunostomy with 17. Braasch, J. W. and Gray, B. N.: Contranshepatic intubation: A technique for siderations that lower pancreatoduodenvery high strictures of the hepatic ducts. ectomy mortality. Am. J. Surg. 129:48083, 1977. Br. J. Surg. 51:186-94, 1964. 13. Feduska, N. J., Dent, T. L., and Lin- 18. Braasch, J. W., Warren, K. W., and Blevins, P. K.: Progress in biliary stricdenauer, S. M.: Results of palliative ture repair. Am, J. Surg. 129:34-37: operations for carcinoma of the pancre1975. as. Arch. Surg. 103:330-34, 1971. 14. Brooks, J. R. and Culebras, J. M.:- Can- 19. Ring, E. J., Oleaga, J. A., Freiman, D. B., et al.: Therapeutic applications of cer of the pancreas: Palliative operation, catheter cholangiography. Radiology Whipple procedure, or total pancreatec128:333-38, 1978. tomy. Am. J. Surg. 131:516-20, 1976. 15. Buckwalter, J. A., Lawton, R. L., and
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