Hepatic arterial injuries in 3110 patients following percutaneous transhepatic biliary drainage

Quality Assurance in Endoscopy: Which Parameters?

BACKGROUND

The verbalisation of quality standards and parameters by medical societies are relevant for qualitative improvement but may also be an instrument to demand more resources for health care or be a unique characteristic. Within the health care system 3 different quality levels can be defined: structure, process and result quality.

METHODS

The current S2k guideline of the German Society for Gastroenterology (quality requirements for gastrointestinal endoscopy) AWMF registry no. 021-022 provides recommendations based on the available evidence for the structure quality (requirements for equipment, human resources) as well as for the process quality (patient preparation, conduct, documentation) and result quality (follow-up of specific endoscopic procedures).

RESULTS

Based on these recommendations, measurable quality indicators/parameters for the endoscopy have been selected and formulated. General quality parameters for endoscopic examinations are given as well as quality parameters for specific procedures for the preparation, conduct, and follow-up of specific endoscopic interventions.

CONCLUSION

Only the regular review of processes and courses by means of defined measurement parameters builds up the basis for corrections based on facts. In addition, the implementation of recommended standards may be an instrument in demanding more resources from the health care system and, therefore, should be embedded as routine.

Diagnosis and management of hemorrhagic complications of interventional radiology procedures

Image-guided interventions have allowed for minimally invasive treatment of many common diseases, obviating the need for open surgery. While percutaneous interventions usually represent a safer approach than traditional surgical alternatives, complications do arise nonetheless. Inadvertent injury to blood vessels represents one of the most common types of complications, and its affect can range from inconsequential to catastrophic. The interventional radiologist must be prepared to manage hemorrhagic risks from percutaneous interventions. This manuscript discusses this type of iatrogenic injury, as well as preventative measures and treatments for postintervention bleeding.

Percutaneous transhepatic biliary metal stent for malignant hilar obstruction: results and predictive factors for efficacy in 159 patients from a single center

AIM

To investigate and compare the efficacy and safety of percutaneous transhepatic biliary stenting (PTBS) using a one- or two-stage procedure and determine the predictive factors for the efficacious treatment of malignant hilar obstruction (MHO).

METHODS

159 consecutive patients with MHO who underwent PTBS were enrolled between January 2010 and June 2013. Patients were classified into one- or two-stage groups. Independent predictors of therapeutic success were evaluated using a logistic regression model.

RESULTS

108 patients were treated with one-stage PTBS and 51 patients were treated with two-stage PTBS. The stents were technically successful in all patients. Successful drainage was achieved in 114 patients (71.4 %). A total of 42 early major complications were observed. Re-interventions were attempted in 23 patients during follow-up. The cumulative primary patency rates at 3, 6, and 12 months were 88, 71, and 48 %, respectively. Stent placement using a one- or two-stage procedure did not significantly affect therapeutic success, early major complications, median stent patency, or survival. A stent placed across the duodenal papilla was an independent predictor of therapeutic success (odds ratio = 0.262, 95 % confidence interval [0.107-0.642]). Patients with stents across papilla had a lower rate of cholangitis compared with patients who had a stent above papilla (7.1 vs. 20.3 %, respectively, p = 0.03).

CONCLUSIONS

The majority of patients with MHO who underwent one-stage PTBS showed similar efficacy and safety outcomes compared with those who underwent two-stage PTBS. Stent placement across the duodenal papilla was associated with a higher therapeutic success rate.

ACG Clinical Guideline: Primary Sclerosing Cholangitis

Primary sclerosing cholangitis is a chronic cholestatic liver disease that can shorten life and may require liver transplantation. The cause is unknown, although it is commonly associated with colitis. There is no approved or proven therapy, although ursodeoxycholic acid is used by many on an empiric basis. Complications including portal hypertension, fat-soluble vitamin deficiency, metabolic bone diseases, and development of cancers of the bile duct or colon can occur.

Hepatic Tract Plug-Embolisation After Biliary Stenting. Is It Worthwhile?

PURPOSE

PTC and stenting procedures are associated with significant risks including life-threatening haemorrhage, sepsis, renal failure and high mortality rates. PTC tract closure methods are utilised to reduce haemorrhagic complications despite little evidence to support their use. The current study assesses the incidence of haemorrhagic complications following PTC and stenting procedures, both prior to and following the introduction of a dedicated expanding gelatin foam-targeted embolisation liver tract closure technique.

MATERIALS AND METHODS

Haemorrhagic complications were retrospectively identified in patients undergoing PTC procedures both prior to (subgroup 1) and following (subgroup 2) the introduction of a dedicated targeted liver tract closure method between 9/11/2010 and 10/08/2012 in a single tertiary referral centre. Mean blood Hb decrease following PTC was established in subgroups 1 and 2. Kaplan-Meier life-table analysis was performed to compare survival outcomes between subgroups using the log-rank test.

RESULTS

Haemorrhagic complications were significantly reduced following the introduction of the targeted PTC tract closure method [(12 vs. 3 % of subgroups 1 (n = 101) and 2 (n = 92), respectively (p = 0.027)]. Mean blood Hb decrease following PTC was 1.40 versus 0.68 g/dL in subgroups 1 and 2, respectively (p = 0.069). 30-day mortality was 14 and 12 % in subgroups 1 and 2, respectively. 50 % of the entire cohort had died by 174 days post-PTC.

CONCLUSION

Introduction of liver tract embolisation significantly reduced haemorrhagic complications in our patient cohort. Utilisation of this method has the potential to reduce the morbidity and mortality burden associated with post-PTC haemorrhage by preventing bleeding from the liver access tract.

Severe bleeding after percutaneous transhepatic drainage of the biliary system: effect of antithrombotic agents--analysis of 34 606 cases from a Japanese nationwide administrative database

PURPOSE

To investigate the relationship between antithrombotic agents (antiplatelet agents and anticoagulants) and severe bleeding after percutaneous transhepatic biliary drainage (PTBD) for biliary obstruction, or cholecystostomy for acute cholecystitis.

MATERIALS AND METHODS

This retrospective study was institutional review board-approved, and patient consent was waived. Between July 2007 and March 2012, 34 606 patients who underwent PTBD (23 375 patients) or cholecystostomy (11 231 patients) were identified in the Diagnosis Procedure Combination database covering 1119 Japanese hospitals. The association between oral administration of antithrombotic agents prior to the procedure and severe bleeding was evaluated, with adjustment for other potential risk factors, such as age, chronic renal failure, liver cirrhosis, and procedure type. Users of antithrombotic agents were categorized as the continuation group, when they took these agents on the procedure day, or as the discontinuation group, when none were taken. Severe bleeding was defined as bleeding which required red blood cell transfusion or transcatheter arterial embolization within 3 days of the procedure. Univariate and multivariate logistic regression models fitted with generalized estimating equations were performed to evaluate the effect of antithrombotic agents on the bleeding complication.

RESULTS

Overall, 780 of 34 606 patients (2.3%) experienced severe bleeding. In the multivariate model, continuation of antiplatelet agents was significantly associated with severe bleeding versus nonuse (odds ratio [OR], 1.87; 95% confidence interval [CI]: 1.14, 3.05; P = .013), whereas discontinuation of antiplatelet agents showed no association (OR, 0.92; 95% CI: 0.70, 1.20; P = .517). The effect of neither continuation nor discontinuation of anticoagulants on severe bleeding was significant. Other significant risk factors for bleeding included older age, chronic renal failure, liver cirrhosis, academic hospital, and PTBD.

CONCLUSION

The continuation of antiplatelet agents can increase severe bleeding after percutaneous transhepatic drainage, whereas the effect of continuation of anticoagulants was inconclusive.

Biliary issues in the bariatric population

Biliary disease is common in the obese population and increases after bariatric surgery. This article reviews management of the gallbladder at the time of bariatric surgery, as well as imaging modalities in the bariatric surgery population and prevention of lithogenesis in the rapid weight loss phase. In addition, diagnosis and treatment options for biliary diseases are discussed, including laparoscopic-assisted percutaneous transgastric endoscopic retrograde cholangiopancreatography in the patient having bariatric surgery.

Combined interventional radiology followed by endoscopic therapy as a single procedure for patients with failed initial endoscopic biliary access

BACKGROUND

Percutaneous transhepatic cholangiography (PTC) assisted endoscopic retrograde cholangiopancreatography (ERCP) usually requires two separate sessions. There are no reports to support performing the procedures in a single session.

AIM

The purpose of this study was to assess the feasibility and safety of the ERCP rendezvous technique via PTC in a single session for patients with initially failed endoscopic biliary intervention.

METHOD

We conducted a retrospective cohort study in a high volume tertiary referral center. A single experienced endoscopist and two interventional radiologists performed all the procedures. Patient demographics and all the related clinical data from January 2009 to July 2011 were obtained from hospital records. Outcome measures were the overall success rates of completion of the combined PTC and ERCP sessions for biliary drainage. Procedure-related complications (bleeding, perforation, hemobilia, bile leak, pancreatitis or cholangitis) were also assessed.

RESULT

Twenty-three patients (14 men) with a median age of 68 years (range 47-89 years) underwent 26 combined PTC-ERCP as a single procedure. PTC and ERCP were both performed within 6 h of failed ERCP in 19 cases (73 %) and the others within 72 h. A total of 91 % of patients had underlying gastrointestinal metastatic cancers, and a surgically altered pancreaticobiliary system was found in 26 % of patients. Percutaneous biliary access was obtained via PTC in all procedures and successful rendezvous therapy was performed in 23 cases (88 %), which include biliary stone removal with a balloon catheter (n = 7) and biliary prostheses (n = 19). The median procedure length for successful PTC-ERCP rendezvous was 60 min (range 14-147 min). With the mean follow-up of 202 days (range 8-833 days), three immediate procedural complications [asymptomatic pneumoperitoneum (n = 2) and post biliary sphincterotomy bleeding (n = 1)] and two delayed complications (a hemorrhagic shock from a damaged branch of hepatic artery and a biloma with secondary infection) occurred, and there was no procedure-associated mortality.

CONCLUSION

This is the first report assessing the feasibility and safety of a combined procedure of ERCP and PTC in a single session. In experienced hands, the combined approach in a single session is appropriate in selected patients with an acceptable risk.

Demonstration of an occult biliary-arterial fistula using percutaneous contrast-enhanced ultrasound cholangiography in a transplanted liver

We present a case of a biliary-arterial communication as a consequence of the placement of an internal-external biliary drainage catheter in a liver transplant patient diagnosed on contrast-enhanced ultrasound using a novel application by injecting microbubble contrast into the catheter tube. We postulate that this method may be sensitive in identifying occult communications between the biliary tree and the vascular compartment when a catheter drain is positioned, and there is hemobilia or unexplained sepsis.

Management of iatrogenic bile duct injuries: role of the interventional radiologist

Bile duct injuries are infrequent but potentially devastating complications of biliary tract surgery and have become more common since the introduction of laparoscopic cholecystectomy. The successful management of these injuries depends on the injury type, the timing of its recognition, the presence of complicating factors, the condition of the patient, and the availability of an experienced hepatobiliary surgeon. Bile duct injuries may lead to bile leakage, intraabdominal abscesses, cholangitis, and secondary biliary cirrhosis due to chronic strictures. Imaging is vital for the initial diagnosis of bile duct injury, assessment of its extent, and guidance of its treatment. Imaging options include cholescintigraphy, ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter. Depending on the type of injury, management may include endoscopic, percutaneous, and open surgical interventions. Percutaneous intervention is performed for biloma and abscess drainage, transhepatic biliary drainage, U-tube placement, dilation of bile duct strictures and stent placement to maintain ductal patency, and management of complications from previous percutaneous interventions. Endoscopic and percutaneous interventional procedures may be performed for definitive treatment or as adjuncts to definitive surgical repair. In patients who are eligible for surgery, surgical biliary tract reconstruction is the best treatment option for most major bile duct injuries. When reconstruction is performed by an experienced hepatobiliary surgeon, an excellent long-term outcome can be achieved, particularly if percutaneous interventions are performed as needed preoperatively to optimize the patient's condition and postoperatively to manage complications.

Comparison of technical success and complications of percutaneous transhepatic cholangiography and biliary drainage between patients with and without transplanted liver

OBJECTIVE

The purpose of this study is to compare technical success and complications of percutaneous transhepatic cholangiography (PTC) and percutaneous transhepatic biliary drainage (PTBD) between patients with and without transplanted liver.

MATERIALS AND METHODS

Between 2007 and 2011, 89 PTCs, including 34 PTBDs, in 87 patients with transplanted liver were attempted, and 131 PTCs, including 118 PTBDs, in 126 patients without transplanted liver were attempted. Technical success, diameters of the bile ducts, fluoroscopy time, and complications were statistically compared between the two groups.

RESULTS

The technical success rate of PTC for transplanted liver was significantly lower than that for nontransplanted liver (88.8% vs 98.5%; p = 0.004). Consequently, the technical success rate of PTBD for transplanted liver was also significantly lower than that for nontransplanted liver (75.0% vs 95.8%; p < 0.001). The average diameters of the first branches and second branches of the bile ducts of transplanted liver were significantly smaller than those of nontransplanted liver (5.8 ± 3.4 mm vs 8.7 ± 3.9 mm for the first branches [p < 0.001]; and 3.7 ± 1.7 mm vs 5.8 ± 2.4 mm for the second branches [p < 0.001]). No significant difference of fluoroscopy time of unilateral successful PTBD was observed (21.8 ± 11.7 vs 19.3 ± 12.9 min; p = 0.372), and no significant difference of overall complication rates was observed (8.0% vs 8.7%; p = 1.000) between transplanted and nontransplanted liver.

CONCLUSION

The technical success rates of PTC and PTBD for transplanted liver are slightly lower than those for nontransplanted liver because the bile ducts are smaller. There is no significant difference in complication rate.