A randomized trial of percutaneous transhepatic cholangiography with the Chiba needle versus endoscopic retrograde cholangiography for bile duct visualization in jaundice

Sixty consecutive patients, who were deeply jaundiced or in whom intravenous cholangiography had failed, were randomized to retrograde endoscopic cholangiography or percutaneous transheptic cholangiograhy with the "skinny" Chiba needle technique. Twenty-eight patients were assigned to retrograde cholangiography, which succeeded in 17 (65%). Percutaneous cholangiography was successful in 16 (50%) of the remaining 32 patients. When patients in whom the first procedure was unsuccessful were reinvestigated by the alternative technique, retrograde cholangiograms were obtained in 13 (81%) of 16, and percutaneous cholangiograms in 8 (73%) of 11. Thus, one or the other technique was successful in 54 (90%) of 60 patients. When the results were analyzed separately for extrahepatic (29 patients) or intrahepatic (31 patients) cholestasis, percutaneous cholangiography was successful in 95% of patients with extrahepatic cholestasis but in only 25% with intrahepatic cholestasis. Endoscopic retrograde cholangiography successded in 63% of patients with extrahepatic and 76% with intrahepatic causes of cholestasis. Complications occurred only in patients with extrahepatic cholestasis. Cholangitis and septicemia occurred in 1 patient after retrograde cholangiography and in 2 after the percutaneous technique. An intraperitoneal bile leak occurred in one other patient after percutaneous cholangiography. Percutaneous cholangiography with the narrow needle is a simple, inexpensive, and reliable method for demonstrating the biliary system and is usually successful when an extrahepatic cause of cholestasis is present. The occurrence of serious complications in patients with extrahepatic cholestasis, despite prophylactic antibiotics, makes provision for early surgery mandatory after both techniques.

Percutaneous antecubital transvenous cholangiography. A modified technique using a flexible needle

A percutaneous antecubital transvenous cholangiography technique using a flexible 20 gauge needle is described. The porcedure was successful in 6 patients with obstructive jaundice but failed in 2 patients without bile duct dilatation. The authors feel that this technique is easier and safer than present transvenous methods. Modifications for the femoral approach and use of the technique in pediatric patients are described.

Fine needle cholangiography in the diagnosis of persistent jaundice. A case report

The fine needle technic utilizes a sleeveless, thin, flexible needle for transhepatic cholangiography. This needle can enter small or normal bile ducts in a high percentage of patients. The value of fine needle cholangiography is illustrated in a patient with a stenosis of the common hepatic duct and a left hepatodochalduodenal fistula which eluded diagnosis by all other methods. The use of this technic is described as an alternative procedure to endoscopic retrograde cholangiography when the latter is technically impossible or as an adjunct to intraoperative extrahepatic cholangiography.

A simple effective technique for performing intraoperative cholangiography

This simple, effective technique for performing intraoperative cholangiography uses a smooth-tipped side port cannula that is easily threaded into the cystic duct. Performance of intraoperative cholangiography is expedited by this method and artifacts commonly produced during cholangiography are avoided.

Current status and usefulness of operative cholangiography

This article is a review of the recent literature on operative cholangiography. The objective is to summarize concisely the important contemporary viewpoints as an aid to students of radiology. To the practicing radiologist, it may offer a concise review of the subject and facilitate upgrading operative cholangiography in his hospital. The introduction covers statistical evidence of the growing dependence of biliary tract surgeons on operative cholangiography. The rudiments of diagnoses of the various diseases that can be detected by operative cholangiography are presented. Pertinent clinical facts along with cholangiographic diagrams are presented under arbitrary sections: I. Stones; II. Anomalies; III. Other Diseases; IV. Techniques of Operative Visualization of the Biliary System.

[Concrement in the biliary tract-Problems of endoscopic and radiological diagnosis-Possibilities of endoscopic therapeutic measures]

The scope of diagnosis of diseases of the biliary tract has been considerably amplified by the addition of retrograde endoscopic cholangiography. With appropriate indications and technique, it is superior to the conventional radiological methods. The method is particularly indicated in biliodigestive anastomoses, the probing of which usually presents no problems, The diagnosis and therapeutic possibilities-removal of foreign material from the biliary tract after radiological visualisation in a single operation-are discussed with reference to three cases. Useful additions to the conventional equipment are the modified Dormia basket and the Fogarty catheter.

[Indications for and effectiveness of retrograde cholangiopancreatography]

The practical value of endoscopic retrograde cholangiopancreatography (ERCP) has been evaluated on the basis of experience in 159 own examinations. The cannulation rate as an important index of the success rate rose with experience, and was 85 percent in the last 110 cases. Diagnostic information was however obtained only in 65 percent, as it was not always possible to cannulate the appropriate ductule system and differentiation between chronic inflammatory and neoplastic pancreatic disease was often difficult. The greatest reliability was found in bilary duct disease, though the difference as compared with pancreatic disease was not significant. With strict limitation of the indication and a few important precautions (avoiding parenchymography of the pancreas and prompt surgical drainage of an obstructed biliary duct or pancreatic pseudocysts) no severe complications were observed throughout this series. The morbidity was thus limited to 4 cases of pancreatitis of moderate severity. In spite of the limitations of ERCP in differentiating malignant from chronic inflammatory pancreatic disease, the method was valuable for establishing the indication for, and planning, surgery. Furthermore, the diagnostic reliability was improved by combining ERCP with selective pancreatic angiography.

Recent advances in the endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography can become a safe and easy procedure by means of sterilization of the instruments. Administration of antibiotics or chemotherapeutic agents, both systemically and mixed with the contrast material, and measurement and control of the injection pressure of the contrast medium using a manometer are employed to achieve as aseptic an operation as possible. For diagnosis of pancreatic cancer in its early stage, as well as diagnosis of minimal and moderate chronic pancreatitis, opacification should extend into not only the main pancreatic duct, but also branches of the pancreatic duct and fine pancreatic ducts. The procedure is one of the most reliable methods for the detection of diseases of pancreatic and biliary systems, especially for the diagnosis of space-occupying lesions such as malignant tumors, and chronic inflammatory changes of the pancreas, as well as differential diagnosis in jaundiced patients.

Duodenoscopy and endoscopic retrograde choledochopancreatography: present position in relation to periampullary and pancreatic cancer

Duodenoscopy and endoscopic retrograde choledochopancreatography represent a major advance in the diagnosis of periampullary and pancreatic lesions. Instruments, techniques and complications are reviewed. A combination of endoscopy and ERCP will yield diagnosis in a high proportion of patients suspected of pancreatic or ampullary carcinomata. Information is obtained which is not only of diagnostic value but is important in the surgical treatment of such patients.

Cholecystectomy cholangiogram snare

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The value of radiomanometry in bile duct surgery

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Cannulation of the papilla of Vater by endoscopy and retrograde cholangiopancreatography (ERCP)

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