ročník 11,2003 č.4
Kongres

Percutaneous transhepatic procedures in treatment of bilary obstruction

Peregrin, JH.

Department of diagnostic and interventional radiology,
Institute for clinical and experimental medicine (IKEM)
Prague

Causes of biliary obstruction

Malignant
pancreatic tumors
gall bladder tumors
cholangiocarcinoma (Klatskin tumor)
hepatoma
metastasis (incl. lymph- node metastases)
Benign
stones
iatrogenic stricture
biloma in (iatrogenic) bilary injury
sclerosing cholangitis
(bi)hepaticoenteroanastomosis stenosis
Mirizzi syndrome

Aims of biliary percutaneous procedures

- To treat obstructive jaundice.
- To treat cholangitis and associate jaundice.
- Preoperative bilary decompression to improve liver function and to lower surgical morbidity.
- After failed attempt at endoscopic bilary drainage with stent placement.

Types of biliary drainage according to patients clinical management

Preoperative
Aim: To remove bilirubinemia and improve renal functions. To prevent cholangitis. As the drainage is intended as temporary measure, it can be external only, but patient will lose fluids, biliary salts and electrolytes. External-internal drainage, although more technically demanding is more secure (catheter end can be locked in the bowel) and gives better comfort to the patient (Fig.1.)
Palliative
Aim: To remove bilirubinemia and prevent cholangitis till the end of patient's live (in malignant non-operable tumors). It can be used as an access to endobilary radiation brachytherapy. Is should give the most possible comfort to the patient. It can be exchanged for internal plastic or metal stent (Fig.2.)(Fig.4.)
Therapeutic
Aim: To remove obstruction in benign biliary stenoses. (?repeated dilatations, ?exchangeable plastic stents, ?metal stents) (Fig.5.)

Stents

Plastic
10 - 12 F, easy to insert, low price (Fig.2.). Average patency rate 3-5 months. If obstructed, in some cases it is possible to exchange them by endoscopy.
Metal
Usually selfexpandable (Fig.4.)(Fig.6a.). Implanted on 6-7 F shaft, expanded diameter 8 - 10 mm, balloon dilatation usually necessary. Higher price. Average patency rate 6 - 8 months. When occluded, they are not possible to be exchanged, but sometimes it is possible to prolong their patency by balloon re-dilatation or it is possible to implant a plastic stent through occluded metal stent (Fig.6e.).
Causes of stent occlusion:
Mucosal debris and bile salts incrustation.
Tumor overgrowth (Fig.6e.) (growth of the tumor beyond the margins of the stent).
Tumor ingrowth (growth of the tumor through the wire mesh of the metal stent).
The relatively poor long-term patency rates of all types of biliary stents make them a poor choice in benign biliary stenoses.

Approach to benign biliary strictures

External internal drainage, in bihepaticoenteroanastomoses the drainage is bilateral. Balloon dilatation of the stricture (8 - 10 mm balloon, inflation for 5 - 10 minutes high pressures are often necessary). Balloon dilatation can be repeated. External - internal drainage by 10 - 12 F catheters for 2 - 3 months as a prevention of restenosis (Fig.5.).
In spite of all procedures a recurrence rate of the obstruction is 50 - 70 % and is treated by repeated dilatation, if it fails a permanent external-internal drainage is necessary (another alternative is surgery).

Drainage technique

Prior procedure a hemocoagulation profile should be checked, INR should not to be lower than 2 (Quick test 50 - 60 %). Prophylactic antibiotics should be administered.
Right sided drainage
Initial puncture by skinny needle from Rt. axillary approach from 10th - 11th intercostal space. The puncture aims horizontally and cranially towards 12th vertebral body. When a bile duct is fond (by repeated needle passes and gentle injections of contrast) a cholangiography is performed. When punctured bile dust is not anatomically suitable for approach to common bile duct and papilla, a duct more suitable for further manipulation is to be punctured. The duct is probed by 0.018" guidewire and later on 0.035" guidewire/catheter system is introduced. To catheterize the common bile duct and to pass through the papilla a torque control guidewire or hydrophyllic guidewire with preshaped catheters are of the necessary (Fig.1.).
Left sided drainage
Initial puncture is subxiphoid; needle is angled 30 - 40 degrees to the right in the transverse plans. An ultrasound guided puncture is often helpful. The common bile duct and further procedure is the same as in right-sided approach (Fig.3.).

Drainage complications (5 - 20 % of procedures)

Bleeding
Sepsis
Bile duct perforation
Pneumothorax
Fluido(bilo)/hemothorax

Address for correspondence:

Peregrin, JH, MD, PhD.
Department of diagnostic and interventional radiology
IKEM Prague
Czech republic