Advanced percutaneous transhepatic biliary access

Complications of percutaneous transhepatic cholangiography and biliary drainage, a multicenter observational study

OBJECTIVES

Over 2500 percutaneous transhepatic cholangiography and biliary drainage (PTCD) procedures are yearly performed in the Netherlands. Most interventions are performed for treatment of biliary obstruction following unsuccessful endoscopic biliary cannulation. Our aim was to evaluate complication rates and risk factors for complications in PTCD patients after failed ERCP.

METHODS

We performed an observational study collecting data from a cohort that was subjected to PTCD during a 5-year period in one academic and four teaching hospitals. Primary objective was the development of infectious (sepsis, cholangitis, abscess, or cholecystitis) and non-infectious complications (bile leakage, severe hemorrhage, etc.) and mortality within 30 days of the procedure. Subsequently, risk factors for complications and mortality were analyzed with a multilevel logistic regression analysis.

RESULTS

A total of 331 patients underwent PTCD of whom 205 (61.9%) developed PTCD-related complications. Of the 224 patients without a pre-existent infection, 91 (40.6%) developed infectious complications, i.e., cholangitis in 26.3%, sepsis in 24.6%, abscess formation in 2.7%, and cholecystitis in 1.3%. Non-infectious complications developed in 114 of 331 patients (34.4%). 30-day mortality was 17.2% (N = 57). Risk factors for infectious complications included internal drainage and drain obstruction, while multiple re-interventions were a risk factor for non-infectious complications.

CONCLUSION

Both infectious and non-infectious complications are frequent after PTCD, most often due to biliary drain obstruction.

Benign Biliary Strictures: Diagnostic Evaluation and Approaches to Percutaneous Treatment

Interventional radiologists are often consulted to help identify and treat biliary strictures that can result from a variety of benign etiologies. Mainstays of noninvasive imaging for benign biliary strictures include ultrasound, contrast-enhanced computed tomography and magnetic resonance imaging, magnetic resonance cholangiopancreatography, and computed tomography cholangiography. Endoscopic retrograde cholangiography is the invasive diagnostic procedure of choice, allowing both localization of a stricture and treatment. Percutaneous biliary interventions are reserved for patients who are not candidates for endoscopic retrograde cholangiography (eg, history of distal gastrectomy and biliary-enteric anastomosis to a jejunal roux limb). This review discusses the roles of percutaneous transhepatic cholangiography and biliary drainage in the diagnosis of benign biliary strictures. The methodology for crossing benign biliary strictures, approaches to balloon dilation, management of recalcitrant strictures (ie, large-bore biliary catheters and retrievable covered stents), and the expected outcomes and complications of percutaneous treatment of benign biliary strictures are also addressed.

Internalization of a second transhepatic biliary access with a captured microwire forced-buckle maneuver: description, anatomic applications, and results

Percutaneous biliary drains are classified into external and internal/external drains. Internal/external drains can drain bile externally and internally (ie, anatomically) into bowel. Internal drainage is usually desired because it is associated with less morbidity. Not infrequently, operators encounter a situation in which one of two transhepatic biliary access tracts has been successfully internalized, and a second access cannot be internalized. The present report describes a technique that internalizes a second percutaneous transhepatic biliary access-relying on an initially successful first internalization-by capturing a microwire from the externalized to the internalized tract and forcing it down into the bowel. The anatomic applications and results of this technique are described.