transhepatic cholangiography combined with ... - AJR

FEBRUARY,

TRANSHEPATIC CHOLANGIOGRAPHY WITH SPLENOPORTOGRAPHY IN PANCREATIC CARCINOMA* By

HARRY

MILLER, JOSEPH and

M.D.,f LOUIS R. M. DEL D. COHN, M.D., NEIL R. RAMA P. COOMARASWAMY, NEW

BRONX,

P ERCUTANEOUS

this

has

procedure

been

with

percutaneous

order the extent At the Bronx

portography

delineate process.

spleno-

to more of the Municipal

in

completely obstructing Hospital

From

t Presently Supported

the

Departments at Coney

of Radiology Island

Hospital,

in part by U. S. Public

and

Surgery

Brooklyn,

Health

Service

New

of the

GUERCIO, M.D., FEINS, M.D., M.D.

Becton,

Dickinson

and

Co.,

Ruther-

ford, N. J.) were used. During performance of the splenoportography, a radiopaque skin marker was placed over the proposed site of skin puncture for the transhepatic cholangiography. This point was usually cm. below the right costal margin in the mid-clavicular line. When the anteroposterior splenoportograms were examined, the relation of the needle site to the portal vein bifurcation could be seen. This made it possible to direct the 12 cm. 20 gauge spinal needle accurately towards the hilus of the liver where the larger bile ducts are more likely to be found. Following removal of the stylet and attachment of saline filled flexible tubing, the needle was withdrawn from the liver, millimeter by millimeter, until bile was aspirated. As much bile as possible was removed and the biliary tree was filled with 50 per cent diatrizoate sodium solution (hypaque). After sufficient contrast material had been injected during visualization with image intensification, an anteropostenor roentgenogram was taken and the needle was removed. The patient was then maneuvered into various positions to ensure that the ductal system had been completely filled. A roentgenogram is also taken in the 3

Albert

Einstein

College

of Medicine,

York.

Research

F.A.C.S.,

YORK

8o-S,

Center, I 5 such combined examinations were carried out and they aided in the practical clinical management of these patients. All of the examinations were elective procedures usually performed just before the exploratory laparotomy for obstructive jaundice. They were done immediately before surgery in order to lessen the danger from bile leakage or hemorrhage. Splenoportography was attempted first and transhepatic cholangiography was undertaken immediately after these serial films had been seen and interpreted. Our technique for performing splenoportography has been previously described.3’5 Since there is seldom significant splenomegaly in these patients, autogenous, heat-denatured chromium 5 I tagged red blood cells were injected intravenously.7 A scintillation counter was placed in different positions over the left upper quadrant of the abdomen and over the left lower lateral costal margin. Scanning was done and the needle was later directed towards the point of maximum radioactivity.4 When this technique was used, it was always possible to find the B

COMBINED BILIARY

splenic pulp with the first puncture. A volume of 40 ml. of 66.8 per cent sodium iothalamate (conray_4oo) was injected in 10 seconds through an i 8 gauge spinal needle. A Stirling, manual, lever operated, pressure injector (Number AD-474o, Charles Thackray, Ltd., Leeds, England) and a 50 ml. plastic syringe (Number

transhepatic chodescribed in flumerous recent articles. The diagnostic value of this examination for patients with extraparenchymal obstructive j aundice is well established. However, no reference has been made regarding the combination of langiography

1966

Grant

468

No.

FR-66 OG i

RISI.

Bronx,

New

York.

96,

\OL.

erect

No.

iranshepatic

2

position

so

gallbladder lilese

two

getlier

edge,

an(.1

also

tile

prior

surgeon

to

operative

to

ment,

veins

to

(_)f this

Illa\’

Ilot

possible

metastatic

superior

ulesenteric

VC1lI

cava,

tOgrapil

.

during

pres-

invariably

found

since

man\’

areas

disease, vein

visualized

b’

cases v

however,

of

splenopor-

posterior

to

defects

in which performed,

w as

assess

biplane tii e

to

the

hepatic

the

pan-

nature

of

the

stone.

demonstrating ampulla

lile

nlajoritv

noma

of

of

the

complete

cases

Iii our

of

series

1)arium

bined

of

transii

ilelptul

epatic

altiiough,

in

creas,

the seen

011

tile

or

110

correlation

impression

year

old

M.R. male

with

to tile

comand

y

par

was

but

the

portal

patient gallbladder

us

to diagnose

and

pa1creatic

I1()

the

portal

region,

free of pathology. found to have

was

with evidence

duct of

or splenic

CASE

C.l).

11.

of

we were At operation,

and

with

extension

correct

presence

a carcinoma

stones

hepatic

VZt5

the

the

cause the

al)le of of

invasion

to

the the the

obstruction. ‘I’here to the vicinity’ of’

veins.

(B.\1.H.C.

18165S),

an

elderly marked

also

came

tile advanced

obstructi

ye

j au ndice. The splenoportogranl B) showed complete obstruction vein with collateral veins drain-

tile in

upper any of

( Fig. 3, Il atid

T5R905),

hospital

with

varices. The transhepatic (Fig. 4, A and B) demonstrated complete obstruction of the common bile duct with dilatation of the ductal system. The characteristic convex contour at the point of oh-

cholangiogram

suggested head of the

the diagnosis of carcinoma pancreas and the spleno-

portographic findings suggested that was far advanced and unresectahie.

an

with

to the

of the splenic ing into gastric

struction of the

CASES

presented

tumor

woman,

mentioned.

patient,

by

ticularl’

with noted

(B.M.H.C.

The wa

common

system.

gastrointes-

not of

card-

tile

series

I.

tile

roost of

ILLUSTRATIVE CASE

biliar\’

prior

invaded

not.

enabled obstruction

state,

ilead of the panof an extrinsic mass loOn of tile duodenum.

carcinonla

lesions

of

tile

were

of

otiler

those

cholangiograph

v

gastrointestinal

stric-

presented.

pancreas

made

cases

Little

benign are

the

of patients, studies

splenoportograph

the

were

head

obstruction

tinal

was

a of Vater

was

in a patient ‘I’he common

standing obstructive jaundice. Splenoportography tOlk)Wed iflinlediately by transhepatic cholangiography was perlormed before surgical exploration. ‘I’he splenoportogranl (Ii’ig. i showed a normal splenic and portal vein but the transhepatic cholangiogram (Fig. 2, 1 and B) demonstrated a mass invading the common hepatic duct, with evidence of a stone in the distal end of the common bile duct. Dilatation of the ductal system itself was also seen. These

genograns tile

splenoportogram of the gallbladder.

duct

was

studies of the

of

Normal

i.

carcinoma

vein

tumor and its extent.5 Our illustrative cases include carcinomas of the hepatic ducts, gallbladder, ampulla of Vater and pancreas. In addition, roenttore

Case

I.

with

splenopor-

filling

as

phase

those

l’IG.

of

as tile inferior

Illetastases,

veiograii

us

such the

or

revealed

be

helped

the

be true,

of collaterals

creas

in

rnalignanc’, corollary

splenoportograph

absence

displace-

Tile

Ilot

In

an’

cure.6

C

tile

tography.

tile

was

Hepati

iisuallv

C1fl

If

for

are

\‘

the

advance.

pancreatic

lesion at operation be unresectal)le

tile

enables

occlusion

or

of

knowland

showed

or

I)iliarv

of

appraisal

This

approach

in

deformity

ence

to-

exploration,

tile

plan

portal

or

tile

diagno-

an

lesion.

procedure

splenic

of

anatomic

permit

of

gaitled

the

filling performed

accurate

an

resectal)ility

tile

possible

place.

exanlinations

Illake

possible

sis

that

takes

469

Cholangiographv

long-

tion,

this

impression

was

confirmed.

the lesion At opera-

l\’Iiller

470

et (ii.

IEBRlJR\’,

J

1966

(

In

common

duct

0

____

I. 11G.

2.

Case i. (‘4) Transhepatic with i!lVItSiOn of the

male and

III. A.E. underwent transhepatic

tion

of the

hepatic

duct.

(R)

cause

of severe

unremitting

splenoportogram

(Fig.

metastases operation

of the advance the lesion and

venous

knowledge of the uninvolved

the

na-

portal

system.

)

was

entirely

CASE

or tumor extension was was quickly performed

year

old

E.W.

Negro

woman, the second

of

denum. portogram hold-up

Jaundice

(Fig.

7,

ofcontrast

junction.

This

posterior

and

trinsic of the

(B.M.H.C.

IV.

struction

interpreted

lateral due axis

263268),

was found portion

was also 1 and material

was

pressure celiac

-.l5.

a

to have of the

29

obduo-

present. A splenoB) demonstrated at the splenoportal from

the

antero-

roentgenogranls to pathologic lymph nodes.

a

as

ex-

enlargement The trans-

1

carcln:m:to:s

l1G.

of the gallbladder of Vater.

jaundice.

but the transhepatic cholangiogram (Fig. 6, 1 and B) showed complete obstruction of the distal common duct. On the basis of these findings we believed that we would find a resectable tumor of the head of the pancreas. At surgery, it was possible to perform a pancreaticoduodenectomy and no evidence of node The

demonstrating carcinoma found in the ampulla

was

because ture of

negative

lymph found.

sketch

A stone

(B.\I.H.C. 198234), an elderly combined splenoportography cholangiography for delinea-

CASE

The

and

cholangiogram

common

3. Case

pancreas. of contrast portal

II.

There vein.

(A)

Splenoportogram

is complete

material

is seen

and

obstruction in the

spleen.

(B)

ofthe

obstruction

0

sketch showing far advanced carcinoma of#{149} the head of the splenic vein with gastric varices. Subcapsular extravasation

Some

of the

contrast

material

can

be seen

to have

reached

the

96,

\o1.,

No.

Transhepati

2

lI(;. 4. Case

II.

hilc

COi11i1U)n

hepatic showed

(A) duct

Transhepatic cholangiogram with a characteristic convex

cholangiogranis obstruction ‘I’he

of

diagnosis

the of

and

bile

bile

C)

duct

ducts

carcinoma

(B)

and of

the

471

sketch showing due to carcinoma

contour

B and

( Iig. 8, 1, the common

of

dilatation

proximal

Witil

gallbladder.

c Cholangiographv

‘Ehe ance

fusit’orm of the

rather than obstructed

may

material

diagnosis

the complete of the head

have

in this

of \ater was confirmed at surgery and although the lesion WaS technically resectable, the tumor had metastasized to the regional lymph nodes including those surrounding the celiac axis. Several months following the

exploration

pancreat

dice

obstruction of

the

of

the

pancreas.

convex appearof contrast a clue to the correct blunt

column

been

case.

aflll)ullIt

icoduodenectom

tography

performed.

was

currence

of the intrahepatic

plus

metastatic

v,

splenopor-

This

obstruction filling

deposits.

repeat

showed

of defects

This

the

was

a re-

splenic suggestive

later

vein of

confirmed

at autopsy.

old

CASE male

V.

R.l). had

progressive

(B.i\l.H.C. 2 month

a

was

a

technical

cholangiography

the

bile

constriction.

Because

make

portal

attempt

at

contrast material (l’ig. 9, /1 and

a distal evidence

Our

denlonstrated duct was

system

benign

that

in

was

stricture

was excised Operative

rest

normal.

of the

an

colic. B) was

branch

of

was suggestive transhepatic

elderly

and to surgical

3atm-

obstructive

The splenoportograrn normal except for the

right

of an intrahepatic cholangiograrn

portal

( [‘ig.

an

vein. lesion. I I , .I

and B) showed choledocholithiasis and cholecvstolithiasis. In addition, irregularities of the gallbladder lumen and partial obstruction of the common hepatic duct were interpreted its malignant

disease

of the

gallbladder.

of

any to

a normal

upon the

diagnosis

the

This The

long-standing

biliary .1 and

obstructed

indicating

tion

of decided

we

revealed

carcinoma of the distal common out metastases or extension. At of Oddi WLS found.

10,

290787),

fusiform

superimposed

remaining B).

for

with

( 1’ig.

(B.M.l-I.C.

combined splenoportograph’ cholangiographv prior

splenoportography.

and

system

A.C.

VI.

Transhepatic

findings.

successful

venous

sphincter tumor

splenoportogd isten

with was no

of these

a second l)r0Ved

first

failure.

duct

There

stones.

of

demonstrated

common

‘Fhis

‘I’he

jaundice.

raphv

5$ year painless

a

319910),

history

CASE

male, had transhepatic

the

hiliary

was

tree

that

bile duct operation,

locally

and

the no

pancreatograms

of The

the final

ampulla

-‘

of a with-

pancreatic diagnosis

of Vater.

11G.

5.

patient

Case with

the pancreas volvement.

m.

Normal

resectable

without

splenoportogram carcinoma of the

evidence

of lymph

in

a

head

of

node

in-

Miller

472

et al.

I

i It RI

I RI

I (11)1)

0 l’l(;.

Case

.

At

surgical and chvma were CASE

(l’ig.

its

cholangiogram in carcinoma

tree

nature the liver

into

this paren-

of

confirmed.

VII.

but

12,

the

extension

(B.M.H.C. partial ol)structive

,‘.\\‘.

male, had splenoportogram

spects

(A) Transhepatic of the hiliary

exploration,

lesion

elderly The

iii.

was

the

‘I

and

of’ the

gallbladder

There

was

a partial

showed

and

tion

of

amount:of

the

common contrast

massive

bile material

appearance

duct

was

and

seen

a small trickling

through the area ofstenosis into a normal distal duct. At exploration, a carcinoma of the common bile duct was found and it was assessed to be surgically resectable.

re-

cholangiogram

intrahepatic

obstruction

an

jaundice. in all

normal

transhepatic

B)

297738),

and (B) sketch showing typical of the head of the pancreas.

DI S C U S S I 0 N

distention

bile of the

Ill

ducts.

all

cases

portographv

midpor-

in and

wilicil transhepatic

conibined

splenocholangiog-

..

partial spI.no

Fi;.

7. Case IV. (A) Splenoportogram and (B) sketch in a young woman. The lesion was resectable but the the obstruction at the splenoportaljunction, precluded

obstruction of portal junction

demonstrating

carcinoma of the ampulla of Vater to the celiac lymph nodes, shown here as the possibility ofa surgical cure,

metastases

96,

\on.

No.

Transhepatic

2

Cholangiograph

z_

gall

I’m.

8. Case

showing

the head

iv. the

(A

dilated

of the

-

bladder

and

B)

gallbladder

pancreas.

473

obstructed bile duct

Different and

views

total

and (C) obstruction

composite of the

sketch common

common

of the transhepatic bile duct secondary

cholangiogram to carcinoma

of

lIC. 9. Case demonstrating was normal

v.

raph\’

used,

(A) Splenoportogram what later has proven in all respects.

was

assessment

of

provided

an the

accurate of

this approach. are elderly and, risks. FFi erefore,

operative technique

which consuming

a time

the head of Splenoportographv

tile

superimposed to be a l)enign

diagnosis

extent

b’

patients

tree.’

By not

can help the surgeon but futile mobilization pancreas

is

itself,

and

is worth a particularly

however,

delineate

tile

portal hepatic, tases.2

of

and

use

of

the

our

nor

inflamof tile

Neither alone or

celiac however,

in the be gained the

from

series

sense from

simple each

of

sum

when

cases,

can reveal

all

transin tra-

axis

metastwo other and these

t each

complemen

than

tamed

primary

obstruction

periportal combination,

are synergistic mation can

a splenoportogram site

In

examinations

biliary

1)iliary

and (B) sketch splenoportogram

malignant from or obstruction

tile

venous pathways. cholangiograph’

hepatic

pursuing. sensiand

causing

cholangiogram of Tater. The

distinguish displacement

it

matorv

avoid

growth

transhepatic of the ampulla

tumor can

1966

IIIIIRIARY,

on the stricture

the lesion were Most of these in general, poor a roen tgenologi c

tive procedure for detecting the spread of tumors of the pancreas can

et cii.

1\liller

474

that more infortheir combined of

tile

data

oh-

used separately. In degrees of involve-

‘I

.--

N

obstruct.d of right

portol

branch v#{149}ln /-_

FIG.

10.

Case

VI.

(A)

Splenoportogram and (B) sketch, and obstructing a branch

the liver

showing carcinoma of the intrahepatic

L)

of the gallbladder portal vein.

extending

into

96,

\oi..

Transhepatic

No.

Cholangiography

475

7

.

I,

mon with

bile

duct

stones

tsl7o l’ic. I I. Case cholelithiasis

vi. (A) Transhepatic and choledocholithiasis,

cholangiognam there are

and

(B)

sketch

irregularities

of

demonstrating the gallbladder

that, in addition to the contour suggestive of

ncoplasm. of the pancreaticobi1iar’

nlent

Ill

all of

the

portal cases

system carcinomas where

an-

associated were abnormality

with noted.

the portal system external compression of

obstruction

(Fig.

was

3/f),

from sligilt to complete

seen,

(Fig. the

7/f)

tunlor

was

found

0 FIG.

12.

Case

VII.

(A)

Transhepatic cholangiogram and (B) sketch showing common bile duct causing a partial ol)struction.

a resectable

carcinoma

of tile

Miller

476

to be tion.

too

far

advanced

for

curative

resec-

et al. 2.

0.,

ARNER,

of dilated

under

Louis

R. M.

Department

Del

Guercio,

M.D.

of Surgery

Albert

Einstein

Bronx

6:, New

College

of Medicine

York REFERENCES

I.

ABEATICI,

S., and

CAMPI,

spl#{233}noportographiques

de l’abdomen 59, 803-834.

L. des

Les caract#{233}nistiques tumeurs

sup#{233}nieur. Acta

chir.

du foie et beig., 1960,

roentgen

H.,

MILLER,

STATE,

oportography

and

with

patients

4. JOHNSON,

and

nondilated

television

R. P.,

COOMARASWAMY,

Obst.,

cholangiography:

bile

ducts

Surgery,

control.

561-571.

1962,52,

3.

S. I.

SELDINGER,

transhepatic

puncture

Splenoportography combined wi th transhepatic cholangiography has been found to be of definite clinical value in determining the cause of obstructive jaundice and in estimating the resectability of biliary pancreatic carcinomas. A series of7 cases illustrating the value of the combined studies is presented.

S., and

HAGBERG,

Percutaneous CONCLUSIONS

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FEBRUARY,

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