Percutaneous Biliary Drainage in Patients With ...

Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y • O r i g i n a l R e s e a r c h Kühn et al. Drainage of Dilated vs Nondilated Intrahepatic Bile Ducts

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Vascular and Interventional Radiology Original Research

Jens P. Kühn1 Alexandra Busemann2 Markus M. Lerch 3 Claus D. Heidecke2 Norbert Hosten1 Ralf Puls1 Kühn JP, Busemann A, Lerch MM, Heidecke CD, Hosten N, Puls R

Keywords: bile duct interventions, biliary system, percutaneous transhepatic biliary drainage DOI:10.2214/AJR.09.3461 Received August 9, 2009; accepted after revision March 2, 2010. 1 Department of Diagnostic Radiology and Neuroradiology, Ernst Moritz Arndt University, Sauerbruch-Strasse 1, Greifswald 17489, Germany. Address correspondence to J. P. Kühn ([email protected]). 2 Surgical Clinic, Department of General, Visceral, Thoracic, and Vascular Surgery, Ernst Moritz Arndt University, Greifswald, Germany. 3 Department of Medicine, Ernst Moritz Arndt University, Greifswald, Germany.

AJR 2010; 195:851–857 0361–803X/10/1954–851 © American Roentgen Ray Society

AJR:195, October 2010

Percutaneous Biliary Drainage in Patients With Nondilated Intrahepatic Bile Ducts Compared With Patients With Dilated Intrahepatic Bile Ducts OBJECTIVE. The purpose of this article is to compare the technical success and guidance of percutaneous transhepatic biliary drainage (PTBD) in patients with nondilated and dilated bile duct systems using different techniques to supplement the conventional approach. MATERIALS AND METHODS. Between 2006 and 2008, 71 patients (mean age, 66.6 years) underwent PTBD with 97 interventions. According to sonographic evaluation of bile duct morphology, patients were divided into two groups: 50 patients with dilated and 21 patients with nondilated bile ducts. In a retrospective analysis, both groups were compared for technical success, fluoroscopy time, complications, and medical indications. The use of interventional guidance (deviations from the standard protocol) in patients with nondilated bile ducts was recorded. RESULTS. The technical success rate was 90% in patients with dilated bile ducts versus 81% in patients with nondilated ducts, with no significant difference (p = 0.36). The greater complexity of the intervention in patients with nondilated bile ducts resulted in longer fluoroscopy times (p = 0.04). Complication rates were not different between the two groups. The main indication for PTBD was relief of a compressed biliary system in patients with dilated ducts and postoperative management of complications or prevention of tumor-associated bile duct obstruction in patients with nondilated ducts. T-drainage, additional CT-guided puncture, and temporary gallbladder drainage were performed in 16 of 21 interventions for patients with nondilated bile ducts, resulting in a 100% success rate, versus a success rate of 60% in the five PTBDs of nondilated ducts performed in the conventional manner. CONCLUSION. T-drainage, additional CT-guided puncture, and temporary gallbladder drainage improve the technical success of PTBD when used in patients with nondilated bile ducts. With these measures, technical success and complication rates in patients with nondilated ducts are comparable to those for PTBD of dilated bile ducts.

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ercutaneous transhepatic biliary drainage (PTBD) is an established intervention for treating patients with biliary obstruction [1]. PTBD has been used for relieving obstructed bile ducts since the 1970s. The technique has also been used for temporary drainage in the management of patients with nondilated bile ducts, but published experience is still limited. Endoscopic retrograde biliary drainage is usually preferred in patients with nondilated bile ducts because it has a higher success rate and fewer complications [2]. However, endoscopic retrograde biliary drainage cannot be performed in all patients and is precluded, for example, in patients who have undergone anatomy-altering surgery, such as Roux-en-Y anastomosis. The first clinical studies of PTBD in patients with

nondilated bile ducts reported a technical success rate of less than 25%, with a complication rate of more than 21% [3, 4]. Current surgical guidelines recommend PTBD in patients with nondilated bile ducts for the management of postoperative complications, such as failed anastomosis after pancreaticojejunectomy, failure of biliodigestive anastomoses, or postoperative leaks of the extrahepatic bile ducts [5]. In this study, we investigate the technical success rate of PTBD in patients with nondilated bile ducts using different techniques to supplement the standard approach. Parameters investigated include indications for the intervention, total fluoroscopy time, and the occurrence of complications of conventional PTBD in patients with dilated and nondilated bile ducts.

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Materials and Methods Study Population Between January 2006 and December 2008, 71 patients underwent PTBD. A total of 97 sessions were necessary. There were 52 men and 19 women, with a mean age of 66.5 years (range, 41–90 years). We retrospectively analyzed the efficiency of the method in relation to bile duct width. All procedures were performed by three interventional radiologists with at least 3 years of experience with interventional techniques. The study design was approved by the local ethics committee.

Definition of Patient Groups Two patient groups were defined on the basis of the width of the intra- and extrahepatic bile ducts and the presence of clinical findings and laboratory parameters indicating cholestasis. The main criterion for assigning patients to either group was the morphologic appearance of the bile ducts at preinterventional ultrasound. Sonographic criteria for bile duct dilatation were a diameter of the common bile duct greater than 7 mm and a diameter greater than 3 mm of intrahepatic segmental or subsegmental branches. Criteria for cholestasis were a total plasma bilirubin level more than five times the upper reference range (0–21 µmol/L) [6, 7] and clinical signs and symptoms of jaundice, brown urine, and discolored stools. The group of patients with sonographically dilated intra- and extrahepatic bile ducts included 50 patients with cholestasis, for whom 70 therapeutic interventions were performed. Preinterventional total plasma bilirubin level in this group was 212.8 µmol/L (range, 16.3–473.4 µmol/L). One patient assigned to this group had clinically suspected Caroli syndrome and a total bilirubin level of 16.3 µmol/L, with sonographic demonstration of segmental dilatation of intrahepatic bile ducts. The second group without sonographic evidence of dilated intra- or extrahepatic bile ducts included 21 patients, who underwent 27 interventions. Total serum bilirubin level in this group was 42.4 µmol/L (range, 6.2–183.8 µmol/L). One patient assigned to this group had a high total bilirubin concentration of 183.8 µmol/L, but no dilatation of intra- or extrahepatic bile ducts was seen.

Indications for PTBD The indications for PTBD are summarized in Table 1. PTBD was performed in all 71 patients after technical failure of endoscopic retrograde biliary drainage. Forty-five patients had tumor-related compression of intra- or extrahepatic bile ducts (42 with dilated bile ducts and three with nondilated bile ducts [protective]), seven patients had inflammatory stricture of the draining bile ducts (four with dilated bile ducts and three with non-

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TABLE 1: Indications for Percutaneous Transhepatic Biliary Drainage (PTBD) in Patients With Nondilated Bile Ducts Versus Those for Patients With Dilated Bile Ducts Indication, Underlying Diagnosis Compression by tumor, extrahepatic

Patients With Dilated Bile Ducts (n = 50)

Patients With Nondilated Bile Ducts (n = 21)

34 (68.0%)

3 (14.3%)

Pancreatic tumor

19

2a

Gallbladder with or without Klatskin tumor

6

0

Papillary tumor

4

0

Other upper abdominal tumors

3

0

Peritoneal carcinosis

2

0

Duodenal metastasis (preoperative)

0

1

Compression by tumor, intrahepatic, liver metastases

8 (16.0%)

0 (0.0%)

Inflammatory compression

4 (8.0%)

3 (14.3%)

Chronic pancreatitis

3

0

Caroli syndrome

1

0

Cholecystitis or cholangitis

0

2

Duodenal ulcer

0

1

Stricture due to postoperative scar formation, common bile duct stricture after cholecystectomy or gastrectomy

4 (8.0%)

0 (0.0%)

Acute management of postoperative failure

0 (0.0%)

15 (71.4%)

Duodenal stump insufficiency

0

6

Biliodigestive anastomosis insufficiency

0

5

Bile duct leakage

0

4

Note—Data are no. or no. (%) of patients. PTBD of dilated bile ducts was performed because of compression of extrahepatic or intrahepatic ducts by tumor in 84% of cases, whereas PTBD of nondilated ducts was performed to manage postoperative complications (insufficiencies) in 71.4% of cases. aPancreatic tumor was preoperative for these two patients.

dilated bile ducts [protective]), and four patients (all of whom had dilated bile ducts) with stricture due to scar formation after upper abdominal surgery. In the remaining 15 patients (all of whom had nondilated bile ducts), PTBD was performed with curative intent for external drainage of bile in the setting of acute management of postoperative complications (e.g., duodenal stump insufficiency).

Standardized PTBD Protocol Patients were premedicated with analgesic (fractionated IV injection of a maximum of 15 mg of piritramide [Dipidolor, Janssen-Cilag] followed by skin disinfection and local anesthesia (20 mL of 1% lidocaine [Xylocitin, Jenapharm]). Next, percutaneous puncture of an intrahepatic bile duct was performed under fluoroscopic guidance (Axiom Artis, Siemens Healthcare) using a fine-needle puncture technique [8]. A 21-gauge Chiba needle (Accustick Introducer System, Boston Scientific Corporation) was inserted between the 10th and 11th rib on the right side. Depending on the interventional radiologist performing the procedure, one of two techniques for ensuring that the needle

tip was positioned in a bile duct was used—either the needle was withdrawn and intraductal placement was assumed, if the fluid aspirated was bile, or the needle was withdrawn while diluted contrast medium was being injected (iodine-based contrast medium mixed one to one with 0.9% physiologic saline solution). Opacification of the bile duct indicated correct intraductal positioning. If necessary, puncture of the peripheral intrahepatic bile ducts was repeated to reduce the risk of subsequent bleeding from the drain by inadvertent puncture of a nearby vessel. This was done without repeat subcapsular puncture. On successful placement of the needle tip in a bile duct, a 0.018-inch guidewire (Accustick Introducer System, Boston Scientific Corporation) was advanced, followed by insertion of a dilatation catheter (4-French dilator and 6-French introducer sheath; Accustick Introducer System, Boston Scientific Corporation) in the Seldinger technique. Next, the initial thin-lumen guidewire was exchanged for a 0.035inch Terumo guidewire (Terumo Medical Corporation). The Terumo guidewire served to probe the central bile ducts (hepatobiliary duct) and was



Drainage of Dilated vs Nondilated Intrahepatic Bile Ducts then advanced through the papilla into the small intestine. After removal of the introducer sheath, the Terumo wire was exchanged for a stiffer steel wire (Amplatz, Boston Scientific Corporation) by means of a 4-French vertebral artery catheter (Cordis). The final PTBD for internal–external drainage was then advanced over the steel wire (8-French Münchener Drainage-Set, Pflugbeil; or Boston Flexima, Boston Scientific).

Data Analysis Success rate—Internal–external drainage is the standardized end point of PTBD in routine clinical interventions at our department because it allows longer-term bile discharge and the metabolic component is compensated. PTBD was considered to be successful if internal–external drainage of the bile ducts with adequate relief of intra- and extrahepatic ducts was achieved. A procedure was classified as partially successful if only external drainage of intrahepatic bile ducts was accomplished because the common bile duct could not be cannulated and no drainage tube could be placed through this duct. The number of interventions per patient was documented. No more than three interventions were allowed per patient. The duration of the entire procedure was at the discretion of the interventional radiologist, who decided when to discontinue the attempt according to the duration of fluoroscopy and patient compliance. Indications—The indications for PTBD were reassessed in a retrospective analysis of all treatments performed in the study population. The indications for PTBD were analyzed and compared for patients with dilated and nondilated bile ducts. Differential approach to PTBD—Various measures not included in the standardized protocol were applied to facilitate PTBD in patients with nondilated bile ducts. These included the use of indwelling T-drains for contrast medium injection, CT-guided puncture of the bile ducts, and puncture or drainage of the gallbladder. These supportive measures were used at the discretion of the radiologists performing the intervention. The procedures are outlined in the next three paragraphs. First, in patients with an indwelling T-drain, the intra- and extrahepatic bile ducts were opacified by injection of at least 20 mL of an iodine-based contrast agent, as for percutaneous transhepatic cholangiography (PTC). Subsequent PTBD was performed according to the standardized protocol described above. Once adequate internal–external drainage was established, the T-drain was removed. Second, in patients who had undergone cholecystectomy but did not have an indwelling Tdrain, the main intrahepatic bile ducts were delineated by preinterventional contrast-enhanced CT. A central bile duct was punctured with a 22-gauge


Chiba needle for PTC using CT guidance. The peripheral ducts were also punctured with CT guidance. PTBD was then performed under fluoroscopic guidance after careful transfer of the patient to the angiography unit. Finally, in patients without an indwelling Tdrain who still had their gallbladder, the gallbladder was punctured using a transhepatic approach, and a temporary gallbladder drain was inserted (8-French pigtail, Pflugbeil). The intrahepatic bile ducts were imaged after injection of at least 40 mL of an iodine-based contrast agent through the pigtail drain, followed by PTBD according to the standardized protocol. The gallbladder drain was removed after 2–5 days. Fluoroscopy time—Fluoroscopy time was evaluated in the two patient groups as an indirect measure of the complexity of the intervention. Fluoroscopy time was defined as the total time of exposure to x-rays per intervention. Complication rate—Morbidity and mortality were documented for the 72-hour interval after the intervention. A longer observation period was not deemed necessary given the multimorbidity of the patient population. The only parameter that was analyzed to evaluate morbidity was hemorrhage affecting hemoglobin levels (parenchymal bleeding, subcapsular hematoma, or bleeding from drains). Bleeding was diagnosed if a decrease in hemoglobin greater than 1.5 mmol/L occurred, or clinical instability was noted, or on the basis of other findings.

Statistical Analysis Mean values of the two groups for number of interventions, outcome of therapy, and fluorosco-

py times were compared using the Student’s t test for unpaired samples. The null hypothesis was that there were no differences between the two groups (dilated vs nondilated bile ducts). The null hypothesis was refuted at a level of significance of p ≤ 0.05. Statistical analysis was performed using SPSS version 17 (SPSS Inc.).

Results The number of interventions per patient, technical success rate, total fluoroscopy time, and complication rate of all interventions and in the two groups (dilated vs nondilated bile ducts) are summarized in Table 2. A total of 97 interventions were performed in 71 patients, resulting in 1.4 ± 0.59 therapeutic sessions per patient. The interventions were successful (internal–external drainage) in 62 (87.3%) of 71 instances. The interventions were partially successful (external drainage only) in seven (9.9%) of 71 cases. No drainage of bile was accomplished in two (2.8%) of 71 patients. In the patients with dilated bile ducts, the intervention was successful in 45 (90.0%) of 50 cases after 1.4 ± 0.63 sessions per patient. External drainage was achieved in five (10.0%) of 50 cases. Thus, bile drainage was accomplished in all 50 patients with dilated bile ducts. In the patients with nondilated bile ducts, the intervention was successful in 17 (81.0%) of 21 patients after 1.3 ± 0.47 sessions per patient. The intervention was partially successful in two (9.5%) of 21 patients. No drainage

TABLE 2: Study End Points in All Patients or Interventions, by Bile Duct Morphology End Point No. of interventions per patient

All Patients

Patients With Dilated Bile Ducts

Patients With Nondilated Bile Ducts

pa

1.4

1.4

1.3

0.403

Successful intervention

0.362

Internal–external drainage

62/71 (87.3)

4 5/50 (90.0)

17/21 (81.0)

External drainage

7/71 (9.9)

5/50 (10.0)

2/21 (9.5)

Failure

2/71 (2.8)

0/50 (0.0)

2/21 (9.5)

Fluoroscopy time, min, mean (range)

19.1 (4.1–74.6)

17.3 (4.1–74.6)

23.8 (5.5–47.6)

0.041

Complication rate Morbidity

9/97 (9.3)

7/70 (10.0)

2/27 (7.4)

0.695

Mortality

2/97 (2.1)

2/70 (2.9)

0/27 (0.0)

0.377

Note—Except where noted, data are no. of patients/total (%). The success rate was not significantly lower in patients with nondilated bile ducts. There were no differences between the two groups of patients in terms of number of interventions or complication rate. The more complex nature of percutaneous transhepatic biliary drainage in patients with nondilated bile ducts is reflected by the significantly longer fluoroscopy times in this group. aPatients with dilated bile ducts versus those with nondilated bile ducts.

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Kühn et al. TABLE 3: Extended Approach to Percutaneous Transhepatic Biliary Drainage (PTBD) in Patients With Nondilated Bile Ducts


Approach, Additional Technique

Cases

Success Rate

Standard approach

5/21 (23.8)

3/5 (60.0)

Extended approach

16/21 (76.2)

16/16 (100)

CT-guided PTC

3/21 (14.3)

N/A

T-drain

8/21 (38.1)

N/A

5/21 (23.8)a

N/A

Gallbladder drainage

Note—Data are no. of patients/total (%). In these patients, the standardized protocol for PTBD was supplemented by additional measures in over 75% of cases. These included CT-guided bile duct puncture with subsequent percutaneous transhepatic cholangiography (PTC), peri-interventional opacification of the biliary system through an indwelling T-drain, and preinterventional puncture of the gallbladder with placement of a temporary drain. N/A = not applicable. aIn one case, internal and external drainage of the bile ducts was accomplished via the gallbladder.

was achieved in two cases (9.5%), and no further interventional procedures were performed in these patients after PTBD failed. There were no statistically significant differences between the two groups in the number of interventions (p = 0.403) and success of PTBD (p = 0.362). Differences were found between the two groups with regard to the indications for PTBD. In the patients with dilated bile ducts, PTBD was performed for tumor-related compression of intra- or extrahepatic bile ducts in 42 (84%) of 50 cases, for inflammatory stricture in four (8%) of 50 cases, and for stricture of the draining bile ducts due to scar formation in four (8%) of 50 cases. The indications for PTBD in the nondilated bile ducts group were management of postoperative complications in 15 (71.4%) of 21 cases (six anastomotic failures after gastrectomy, five anastomotic failures after Whipple operation, and four failures after complicated cholecystectomy) and protective intent in the presence of inflammatory stricture in three (14.3%) of 21 cases or beginning compression of draining bile ducts by tumor in three (14.3%) of 21 cases. The radiologists deviated from the standardized protocol only for the patients with nondilated bile ducts (Table 3). Five (23.8%) of 21 patients with nondilated bile ducts underwent PTBD according to the standardized protocol, which was successful in three (60%) of five cases. CT-guided percutaneous puncture of the bile ducts was performed in three (14.3%) of 21 cases. PTC via an indwelling T-drain was used as a supportive measure in eight (38.1%) of 21 cases. In four (19.0%) of 21 patients, a temporary gallbladder drain was placed for subsequent PTBD. In one patient (4.8%), PTBD was accomplished by puncture of the gallbladder. Drainage was accomplished in all 16 patients with nondi-

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lated bile ducts who underwent PTBD using an extended approach, corresponding to a success rate of 100%. A mean fluoroscopy time of 19.1 minutes (range, 4.1–74.6 minutes) was calculated for 97 interventions. The mean fluoroscopy time was 17.3 minutes (range, 4.1–74.6 minutes) in the patients with dilated bile ducts and 23.8 minutes (range, 5.5–47.6 minutes) in the patients with nondilated bile ducts, which was significantly longer (p = 0.041). Laboratory tests revealed a postprocedural hemoglobin level decrease of more than 1.5 mmol/L in 10 (10.3%) of 97 interventions. In one case, complications were ruled out by clinical findings and imaging (ultrasound and CT). Thus, the morbidity rate due to hemorrhage 0–72 hours after the intervention was 9.3% (9/97 interventions), and the mortality rate was 2.1% (2/97 interventions). The morbidity rate was 10% (7/70 interventions) in the dilated bile ducts group and 7.4% (2/27 interventions) in the nondilated bile ducts group. Both deaths occurred in patients with a dilated biliary system. One patient died of the underlying disease (hepatic metastic pancreatic cancer), and the second patient died because of uncontrollable bleeding. The morbidity and mortality rates in the two patient groups must be interpreted in light of the small number of cases. Discussion Some studies have investigated the technical aspects of PTBD and the management of complications. Only a few centers perform PTBD in patients with nondilated bile ducts, and published experience is still limited. To our knowledge, ours is the first study to directly compare biliary drainage in patients with dilated and nondilated bile ducts. Our data suggest that good results can be achieved

in nondilated bile ducts as well if the procedure is adjusted to the individual situation. In a review, Burke et al. [9] established quality assurance guidelines for percutaneous transhepatic diagnostic and therapeutic biliary interventions [9–12]. A technical success rate of 90.0% was achieved in patients with dilated bile ducts, which is comparable to our results in this subset of patients. For patients with nondilated bile ducts, a technical success rate of only 45.5% is reported. We achieved a much better success rate of 81.0% in these patients, and our technical success rates are not significantly different for dilated and nondilated bile ducts. An even higher technical success rate of 90.0% (117/130) in treating patients with nondilated bile ducts was reported by Funaki et al. [13]. They were the first to report on biliary drainage in the presence of nondilated ducts in a larger patient population. However, they did not directly compare PTBD in patients with dilated and nondilated biliary systems. Different supportive measures (use of indwelling T-drains, CT-guided puncture, or direct puncture of the gallbladder for temporary drainage) that contribute to the success of PTBD in patients with nondilated ducts were not described either. In the past, PTBD was only used to relieve obstructive biliary conditions in patients with dilated bile ducts. Its use in patients with nondilated biliary systems was restricted to specific situations (e.g., if endoscopic retrograde biliary drainage fails or is precluded after anatomy-altering surgery). In 21% of our patients, PTBD was indicated for the management of postoperative complications. Injury to extrahepatic bile ducts, failed biliodigestive anastomosis, and duodenal stump insufficiency are feared complications of complex upper abdominal operations. Internal-external biliary drainage has become an established component of the surgical management of postoperative failure of biliodigestive anastomoses [14, 15]. Sohn et al. [14] and Baker et al. [15] investigated the management of complications occurring after pancreaticoduodenectomy. These two articles describe a total of 56 (49 in one study and seven in the other) PTBDs performed for anastomotic failure, obstructed bile duct segments, or dislodged T-drains. What these two studies did not report in detail are supportive procedures and techniques that can contribute to the success of drainage in patients with nondilated bile ducts. PTBD of nondilated bile duct systems was accomplished with the use of additional techniques for delineation of the intrahepatic bile


Drainage of Dilated vs Nondilated Intrahepatic Bile Ducts


Fig. 1—59-year-old man who underwent complicated cholecystectomy. A, Injection of contrast medium through indwelling T-drain showed contrast medium leakage from bile ducts. Patient’s clinical condition deteriorated, and percutaneous transhepatic biliary drainage (PTBD) became necessary. Indwelling T-drain allows injection of contrast medium for opacification of intrahepatic bile ducts and facilitates PTBD. B, Bile duct was punctured using left-sided approach. C, Wire was advanced into small intestine, bypassing T-drain. D, Eight-French Boston-Flexima PTBD drain was placed, ensuring adequate internal–external drainage.

Fig. 2—54-year-old man with duodenal stump insufficiency after gastrectomy. A, Gallbladder drain was placed using transhepatic approach. Injection of iodine-based contrast medium through drain enabled adequate delineation of intraand extrahepatic bile ducts. B, Proximal intrahepatic duct in right liver lobe was punctured. C, Wire was advanced through common bile duct, and once secure, positioning of wire in small intestine was ensured. D, Eight-French Boston-Flexima percutaneous transhepatic biliary drainage drain was placed.


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Fig. 3—55-year-old woman who underwent complicated cholecystectomy, with bile duct leakage and perforated duodenal ulcer. A, Helical CT reveals delicate intra- and extrahepatic bile duct system. B, Central bile duct was punctured for percutaneous transhepatic cholangiography. C, After careful cannulation of bile ducts, patient was transferred to angiography unit, where successful percutaneous transhepatic biliary drainage was accomplished.

ducts in 76.2% of cases. The decision to use supportive measures was up to the radiologist performing the intervention. In most instances, adequate delineation of the intra- and extrahepatic bile ducts was accomplished by making use of an indwelling T-drain (Fig. 1). In patients without an indwelling T-drain, transhepatic placement of a temporary gallbladder drain can be helpful (Fig. 2). A complication rate of 8.7% has been reported for percutaneous transhepatic gallbladder drainage [16]. None of our patients who underwent gallbladder drainage developed complications. Cannulation of the cystic duct for drainage via the gallbladder was accomplished in one of five cases [17]. CT-guided puncture of a central bile duct with subsequent PTC was found to be helpful (Fig. 3). Successful drainage was accomplished in all patients in whom CT-guided puncture, opacification via an indwelling T-drain, and temporary gallbladder drainage were used. Two failures were documented in the patient group with nondilated bile ducts. In both cases, the standardized procedure was used and no supportive techniques were applied. The wide range of success rates of 25–90% associated with PTBD of nondilated bile ducts is attributable to the use of different interventional strategies [3, 4, 9, 13]. Funaki et al. [13] achieved excellent results because, like us, they used supplementary techniques for opacification of the intrahepatic biliary system. We found fluoroscopy times to be significantly longer for PTBD of nondilated bile ducts, reflecting the greater complexity of the procedure in these patients. Data for comparison with our findings are not available in the literature. Reports on the complications of percutaneous transhepatic biliary drainage com-

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pared with competing endoscopic techniques led to a critical attitude toward PTBD. We analyzed bleeding complications only if they affected hemoglobin levels. Catheter malfunction and infections induced by the procedure were not recorded [1]. Reported rates of bleeding complications after PTBD range from 0.5% to 15%, regardless of whether the procedure is performed in patients with dilated or nondilated ducts [18–25]. We had a morbidity rate due to severe bleeding of 9.3%. The complication rate was slightly lower in the group with nondilated bile ducts (7.3% vs 10.0%). We therefore conclude that morbidity is not significantly different between patients with dilated and nondilated bile ducts. Funaki et al. [13] reported a lower morbidity rate for patients with nondilated bile ducts (total, 3.9%; sepsis, 2.3%; severe bleeding, 0.8%; and pancreatitis, 0.8%). The reported mortality rate of PTBD ranges from 0 to 4.9% [18–25]. Our overall mortality rate was 2.1%. Paralleling the morbidity rate, postinterventional mortality was also lower in patients with nondilated bile ducts. This result may be attributable to the different sizes of the two patient groups examined. It should be noted that our study focused strictly on radiologic aspects of PTBD. Our study is limited by a low number of cases enrolled over a long study period because, in our hospital, endoscopic retrograde biliary drainage is the reference standard method for drainage of bile ducts. PTBD was performed only if endoscopic retrograde biliary drainage was not successful or not feasible. A second limitation is the missing evaluation of ultrasound-guided PTBD in our study design. In a report by Hayashi et al. [26], the technical success rate of PTBD under ultrasound guidance in patients with dilated bile

ducts was 100% at the first attempt. In addition, they successfully created PTBD in 25 of 26 patients with nondilated bile ducts (< 3 mm) under ultrasound guidance. In conclusion, PTBD of nondilated bile ducts can be performed with a high technical success rate and a complication rate similar to that of PTBD of dilated bile ducts, although the intervention is more complex when the bile ducts are not dilated. Different supportive measures, such as an additional PTC, use of an indwelling T-drain, or opacification via a temporary gallbladder drain, facilitate PTBD in patients with nondilated bile ducts and help interventional radiologists achieve a high technical success rate in these patients as well. References 1. Oberholzer K, Pitton MB, Mildenberger P, et al. The current value of percutaneous transhepatic biliary drainage [in German]. Rofo 2002; 174:1081–1088 2. Lee JKT, Sagel SS, Stanley RJ, et al. Computed body tomography with MRI correlation, 3rd ed. Philadelphia, PA: Lippincott-Raven, 1998:780 3. Elias E. Cholangiography in the jaundiced patient. Gut 1976; 17:801–811 4. Teplick SK, Flick P, Brandon JC. Transhepatic cholangiography in patients with suspected biliary disease and nondilated intrahepatic bile ducts. Gastrointest Radiol 1991; 16:193–197 5. Kutup A, Yekebas EF, Izbicki JR. Management postoperativer Pankreaskomplikationen. Chir Gastroenterol 2008; 24:108–114 6. Balistreri WF, Shaw LM. Liver function. In: Tietz NW, ed. Fundamentals of clinical chemistry, 3rd ed. Philadelphia, PA: Saunders, 1987:729–761 7. Thomas L. Labor und Diagnose. Indikation und Bewertung von Laborbefunden für die medizinische Diagnostik. 5. Frankfurt am Main, Germany: THBooks, 2000 8. Günther R, Thelen M. A fine-needle puncture set



Drainage of Dilated vs Nondilated Intrahepatic Bile Ducts for percutaneous bile duct drainage [in German]. Rofo 1980; 133:180–181 9. Burke DR, Lewis CA, Cardella JF, et al. Quality improvement guidelines for percutaneous trans hepatic cholangiography and biliary drainage. J Vasc Interv Radiol 2003; 14(9 Pt 2):S243–S246 10. Mueller PR, van Sonnenberg E, Ferrucci JT. Percutaneous biliary drainage: technical and catheter-related problems in 200 procedures. AJR 1982; 138:17–23 11. Lammer J, Neumayer K. Biliary drainage endoprostheses: experience with 201 placements. Radiology 1986; 159:625–629 12. Dick BW, Gordon RL, LaBerge JM, et al. Percutaneous transhepatic placement of biliary endoprostheses: results in 100 consecutive patients. J Vasc Interv Radiol 1990; 1:97–100 13. Funaki B, Zaleski GX, Straus CA, et al. Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts. AJR 1999; 173:1541–1544 14. Sohn TA, Yeo CJ, Cameron JL, et al. Pancreaticoduodenectomy: role of interventional radiolo-

gists in managing patients and complications. J Gastrointest Surg 2003; 7:209–219 15. Baker TA, Aaron JM, Borge M, et al. Role of interventional radiology in the management of complications after pancreaticoduodenectomy. Am J Surg 2008; 195:386–390, discussion 390 16. vanSonnenberg E, D’Agostino HB, Goodacre BW, et al. Percutaneous gallbladder puncture and cholecystostomy: results, complications, and caveats for safety. Radiology 1992; 183:167–170 17. Kühn JP, Puls R, Maier S, et al. PTCD with a trans hepatic approach over the gallbaldder—relieving a secondary duodenal stump insufficiency after gas trectomy [in German]. Rofo 2007; 179:860–862 18. Lackner K, Steudel A, Bäuerle R, et al. Results of percutaneous transhepatic bile duct drainage [in German]. Rofo 1985; 142:647–654 19. Joseph PK, Bizer LS, Sprayregen SS, et al. Percutaneous transhepatic biliary drainage: results and complications in 81 patients. JAMA 1986; 255: 2763–2767 20. Schoenemann J, Willems M, Wolf G, et al. Re-

sults of percutaneous transhepatic drainage of the bile ducts [in German]. Rofo 1987; 147:619–623 21. Gazzaniga GM, Faggioni A, Bondanza G, et al. Percutaneous transhepatic biliary drainage: twelve years’ experience. Hepatogastroenterology 1990; 37:517–523 22. Hamlin JA, Friedman M, Stein MG, et al. Percutaneous biliary drainage: complications of 118 consecutive catheterizations. Radiology 1986; 158:199–202 23. Weber J, Höver S. Technical problems in percutaneous transhepatic biliary drainage [in German]. Rofo 1985; 143:534–543 24. Lois JF, Gomes AS, Grace PA, et al. Risks of percutaneous transhepatic drainage in patients with cholangitis. AJR 1987; 148:367–371 25. Yee AC, Ho CS. Complications of percutaneous biliary drainage: benign vs malignant diseases. AJR 1987; 148:1207–1209 26. Hayashi N, Sakai T, Kitagawa M, et al. US-guided left sided biliary drainage: nine-year experience. Radiology 1997; 204:119–122

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