Hepatic arterial injuries in 3110 patients following percutaneous transhepatic biliary drainage

Comparing outcomes of right verse left hepatic approach percutaneous biliary drainage catheters

Purpose

Determine if there is a difference in adverse events (AE) between right or left hepatic percutaneous biliary drain placement (PTBD) in patients with biliary strictures.

Materials & methods

This retrospective study included patients with benign or malignant biliary stricture treated with PTBD at a single institution from 7/28/2004-3/30/2021. 357 patients met inclusion criteria, 77 (21.6 %) had PTBD on the left and 280 (78.4 %) on the right. AEs associated with the initial drain placement or during subsequent intervention were collected and categorized. AEs that were grouped as periprocedural included: surgery, infection, hemorrhage, and drain failure. AEs in the postprocedural group included: chills, catheter displacement, cholangitis, biliary stones, drain malfunction, fever resolving without treatment, and pericatheter leakage. Surgery was considered a major AE and the remaining AEs were categorized as minor. Statistical analyses were performed using Logistic Regression Analysis and p-values less than 0.05 were considered statistically significant.

Results

Overall, there was no statistically significant difference in AEs between right and left drains in the periprocedural and postprocedural period (p = 0.832, OR = 0.95 and p = 0.808, OR = 0.93 respectively). When analyzing minor AEs individually, only cholangitis occurred at a higher rate on the right side (p = 0.033, OR = 0.43). There was no statistical difference in the rate of major AEs in the periprocedural period between left and right drains (p = 0.311, OR = 1.37).

Conclusion

Current literature is equivocal when comparing right versus left percutaneous biliary drains. This analysis describes no statistically significant difference in AEs between right and left hepatobiliary drains aside from slightly higher incidence of cholangitis for right sided drains.

Bloody Bile and Rescue Intervention-A Case Series of Post-PTBD Hemorrhagic Complications With a Review of the Literature

Percutaneous transhepatic biliary drainage (PTBD) is a routinely performed interventional radiological procedure. A myriad of complications can occur after PTBD, the most important being hemorrhagic complications that require immediate attention. Hemorrhage following PTBD may result from arterial, portal, or hepatic venous injury. A catheter or pull-back cholangiogram often demonstrates the venous injury. A computed tomogram angiogram aids in identifying bleeding sources and procedural planning. Catheter repositioning, upsizing, or clamping often suffice for minor venous bleeding. However, major venous injury necessitates tract embolization, portal vein embolization, or stent grafting. Arterial injury may lead to significant blood loss unless treated expeditiously. Transarterial embolization is the treatment of choice in such cases. Adequate knowledge about the hemorrhagic complications of PTBD will allow an interventional radiologist to take necessary precautionary measures to reduce their incidence and take appropriate steps in their management. This article entails four different hemorrhagic complications of PTBD and their interventional management. It also discusses the various treatment options to manage different kinds of post-PTBD hemorrhagic complications.

Iatrogenic vascular complications of non-vascular percutaneous abdominal procedures

PURPOSE

The purpose of this paper is to compile and present all of the reported vascular complications that resulted from common non-vascular abdominal procedures in the literature. Non-vascular procedures include, though are not limited to, percutaneous abscess/fluid collection drainage (PAD), percutaneous nephrostomy (PN), paracentesis, percutaneous transhepatic cholangiography (PTC)/percutaneous biliary drainage (PBD), percutaneous biliary stone removal, and percutaneous radiologic gastrostomy (PG)/percutaneous radiologic gastrojejunostomy (PG-J). By gathering this information, radiologists performing these procedures can be aware of the associated vascular injuries, as well as take steps to minimize risks.

METHODS

A literature review was conducted using the PubMed database to catalog relevant articles, published in the year 2000 onward, in which an iatrogenic vascular complication occurred from the following non-vascular abdominal procedures: PAD, PN, paracentesis, PTC/PBD, percutaneous biliary stone removal, and PG/PG-J. Biopsy and tumor ablation were deferred from this article.

RESULTS

214 studies met criteria for analysis. 28 patients died as a result of vascular complications from the analyzed non-vascular abdominal procedures. Vascular complications from paracentesis were responsible for 19 patient deaths, followed by four deaths from PTC/PBD, three from biliary stone removal, and two from PG.

CONCLUSION

Despite non-vascular percutaneous abdominal procedures being minimally invasive, vascular complications still can arise and be quite serious, even resulting in death. Through the presentation of vascular complications associated with these procedures, interventionalists can improve patient care by understanding the steps that can be taken to minimize these risks and to reduce complication rates.

Comparative efficacy of sequential treatment and open abdomen approaches for corrosive abdominal hemorrhage due to inadequate drainage of duodenal leakage: a cohort study

BACKGROUND

Intra-abdominal bleeding resulting from inadequate drainage of duodenal leakage (DL) is typically caused by the corrosiveness of duodenal fluid. Open abdomen (OA) treatment addresses both the drainage and bleeding simultaneously. However, a sequential treatment (ST) approach involving hemostasis through transcatheter arterial embolization (TAE) followed by percutaneous drainage of source control has emerged as an alternative method. This study aimed to evaluate the prognosis of ST in cases of DL-induced intra-abdominal bleeding.

METHODS

This retrospective cohort study included 151 participants diagnosed with DL-induced intra-abdominal bleeding from January 2004 to December 2010, and January 2013 to December 2021. The ST and OA groups were established based on the treatment method applied. Propensity score-matching (PSM) matched patients in the ST group with those in the OA group.

RESULTS

Among the 151 patients, 61 (40.4%) died within 90 days after the bleeding episode. ST was associated with a lower mortality rate (28.2% vs. 51.3% adjusted odds ratio [OR] = 0.34; 95% confidence interval [CI] 0.17-0.68; P = 0.003) compared to OA. Following PSM, ST remained the only factor associated with reduced mortality (OR = 0.32; 95% CI 0.13-0.75; P = 0.009). Moreover, ST demonstrated a higher rate of initial hemostasis success before (90.1% [64/71] vs. 77.5% [62/80]; adjusted OR = 2.84; 95% CI 1.07-7.60; P = 0.04) and after PSM (94.4% [51/54] vs. 77.8% [42/54], adjusted OR = 3.85; 95% CI 2.15-16.82; P = 0.04). Additionally, ST was associated with a lower incidence of rebleeding within 90 days after the initial bleeding, before (7 vs. 23; adjusted OR 0.41; 95% CI 0.18-0.92; P = 0.03) and after PSM (5 vs. 14; adjusted OR 0.37; 95% CI 0.15-0.93; P = 0.03).

CONCLUSIONS

Applying ST involving TAE and subsequent percutaneous drainage might be superior to OA in lowering the mortality in DL-induced intra-abdominal hemorrhage.

Effectiveness of ultrasound-guided percutaneous transhepatic biliary drainage to reduce radiation exposure: A single-center experience

Percutaneous transhepatic biliary drainage (PTBD) has been an effective treatment to access the biliary tree, especially in case of endoscopically inaccessible biliary tree. In general, PTBD techniques are divided into two methods: fluoroscopy-guided PTBD and ultrasound (US)-guided PTBD. This study aimed to evaluate the effectiveness of US-guided PTBD, focusing on radiation exposure according to intrahepatic duct (IHD) dilatation degree, differences between right- and left-sided approaches and differences between benign and malignant biliary stenosis/obstruction. We evaluated technical success, clinical success, procedural data (the number of liver capsule punctures, procedural time, fluoroscopy time and radiation dose), and procedure-related complications. During the study period, a total of 123 patients with biliary stenosis/obstruction or bile leakage were initially eligible. We excluded 76 patients treated with only ERCP or initially treated with ERCP followed underwent PTBD insertion. Finally, a total of 50 procedures were performed in 47 patients. Of the 47 patients, 8 patients had anatomical alteration due to previous surgery, 6 patients refused ERCP, and 3 patients failed ERCP. For the remaining 30 patients, PTBD was performed on weekend or at night, 11 of whom had poor general condition, 10 patients underwent ERCP 3 to 4 days later after PTBD insertion, 6 patients improved after PTBD insertion without ERCP, 1 patient died, and 1 patient was referred to other hospital. Remaining 1 patient underwent surgery due to Mirizzi syndrome. All procedures were performed by two interventional radiologists. Technical success rate was 100%, clinical success was 94%, and the complication rate was 10%. Fluoroscopy time and the reported radiation dose were significantly lower in patients with dilated bile ducts than in those with non-dilated bile ducts, when biliary puncture under US guidance was performed initially. However, even in patients with non-dilated bile ducts undergoing initial trials of biliary puncture under US guidance, the fluoroscopy time and the reported radiation dose were low, based on current studies. No statistical significant differences were observed in terms of technical and dosimetry results according to right-sided and left-sided procedures and benign and malignant biliary stenosis/obstruction. Thus, US-guided PTBD was found to be a safe and effective technique that significantly reduced fluoroscopy time and radiation doses.

Biliary Cripple and the Spectrum of Complications following Cholecystectomy: A Case Report

Bile duct injury is a complication seen during cholecystectomy. Here, we highlight the occurrence of bile duct injury (BDI) during an open cholecystectomy who underwent hepaticojejunostomy (HJ), later presenting with a stricture of HJ. Percutaneous transhepatic biliary drainage (PTBD) was performed which led to the development of hepatic artery injury.

Percutaneous transhepatic biliary drainage: a retrospective single-center study of 372 patients

BACKGROUND

Complication rates in percutaneous transhepatic biliary drainage (PTBD) are non-uniform and vary considerably. In addition, the impact of peri-procedural risk factors is under-investigated.

PURPOSE

To compare success and complication rates of PTBD in patients with and without accompanying technical risk factors.

MATERIAL AND METHODS

A single-center retrospective study was conducted from January 2004 to December 2016. Patients receiving PTBD due to biliary obstruction or biliary leakage were included. Technical risk factors (non-distended bile ducts, ascites, obesity, anasarca, non-compliance) were assessed. Complications were classified according to the Society of Interventional Radiology.

RESULTS

In total, 372 patients were included (57.3% men, 42.7% women; mean age = 66 years). Overall, 466 PTBDs were performed. Of the patients, 70.1% presented with malignancy and biliary obstruction; 26.8% had benign biliary obstruction; 3.1% had biliary leakage. Technical risk factors were reported in 57 (15.3%) patients. Overall technical success of initial PTBD was 98.7%, primary technical success was 97.9%. In patients with non-dilatated bile ducts, primary technical success was 68.2%. Overall complication rate was 15.0% (8.1% major complications, 6.9% minor complications). Neither major nor minor complications were more frequent in patients with technical risk factors (P > 0.05). In left-sided PTBD, hemorrhage was more frequent (P = 0.015). Patients with malignancy were significantly more affected by drainage-related complications (P = 0.004; odds ratio = 2.03). The mortality rate was 0.5% (n = 2).

CONCLUSION

PTBD is a safe and effective method for the treatment of biliary obstruction and biliary leaks. Complication rates are low, even in procedures with risk factors.

Procedure-related risk factors for bleeding after percutaneous transhepatic biliary drainage: A systematic review and meta-analysis

BACKGROUND/PURPOSE

Bleeding is the most dreaded complication after percutaneous transhepatic biliary drainage (PTBD). Clarifying the risk factors of bleeding can reduce the morbidity and mortality rates of PTBD. However, the procedure-related risk factors for bleeding after PTBD are still controversial. Therefore, this systematic review and meta-analysis were performed to identify procedure-related risk factors of bleeding after PTBD.

METHODS

PubMed, Cochrane database, and Google Scholar were searched for published studies until 1st May 2021. Inclusion criteria were: studies associated with bleeding complications after PTBD and with sufficient data to compare different procedure-related factors for bleeding. Sources of bias were assessed using the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool for randomised trials. Probable procedure-related risk factors were evaluated and outcomes were expressed in the case of dichotomous variables, as an odds ratio (OR) (with a 95% confidence interval, (CI)).

RESULTS

Eleven studies were included in the meta-analysis. There was no significant difference in bleeding rates with respect to the side of PTBD (left/right, OR = 1.10, 95% CI: 0.68-1.76), the insertion level of bile duct (central/peripheral, OR = 1.39, 95% CI: 0.82-2.35), and the usage of ultrasound guidance (OR: 1.25, 95% CI: 0.60-2.60). A subgroup analysis revealed a left-sided approach that resulted in more hepatic arterial injuries than the right-sided approach (left/right, OR = 1.93, 95% CI: 1.32-2.83).

CONCLUSION

Left-sided approach is a risk factor for hepatic arterial injuries after PTBD.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

Role of Interventional Radiology in the Management of Acute Cholangitis

Acute cholangitis presents with a wide severity spectrum and can rapidly deteriorate from local infection to multiorgan failure and fatal sepsis. The pathophysiology, diagnosis, and general management principles will be discussed in this review article. The focus of this article will be on the role of biliary drainage performed by interventional radiology to manage acute cholangitis. There are specific scenarios where percutaneous drainage should be preferred over endoscopic drainage. Percutaneous transhepatic and transjejunal biliary drainage are both options available to interventional radiology. Additionally, interventional radiology is now able to manage these patients beyond providing acute biliary drainage including cholangioplasty, stenting, and percutaneous cholangioscopy/biopsy.

The Role of the Interventional Radiologist in Bile Leak Diagnosis and Management

Bile leaks are rare but potentially devastating iatrogenic or posttraumatic complications. This is being diagnosed more frequently since the advent of laparoscopic cholecystectomy and propensity toward nonsurgical management in select trauma patients. Timely recognition and accurate characterization of a bile leak is crucial for favorable patient outcomes and involves a multimodal imaging approach. Management is driven by the type and extent of the biliary injury and requires multidisciplinary cooperation between interventional radiologists, endoscopists, and hepatobiliary/transplant surgeons. Interventional radiologists have a vital role in both the diagnosis and management of bile leaks. Percutaneous interventional procedures aid in the characterization of a bile leak and in its initial management via drainage of fluid collections. Most bile leaks resolve with decompression of the biliary system which is routinely done via endoscopic retrograde cholangiopancreaticography. Some bile leaks can be definitively treated percutaneously while others necessitate surgical repair. The primary principle of percutaneous management is flow diversion away from the site of a leak with the placement of transhepatic biliary drainage catheters. While this can be accomplished with relative ease in some cases, others call for more advanced techniques. Bile duct embolization or sclerosis may also be required in cases where a leaking bile duct is isolated from the main biliary tree.

CIRSE Standards of Practice on Percutaneous Transhepatic Cholangiography, Biliary Drainage and Stenting

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

Percutaneous transhepatic cholangiography in the era of magnetic resonance cholangiopancreatography: A prospective comparative analysis in preoperative evaluation of benign biliary stricture

Background and Aim

Accurate anatomical delineation is the key before definitive repair for benign biliary stricture (BBS). The role of percutaneous transhepatic cholangiography (PTC) as a road map is less studied in the era of magnetic resonance cholangiopancreatography (MRCP).

Methods

A prospective observational study, performed between July 2012 and December 2013. All patients of post‐cholecystectomy BBS were evaluated with MRCP and PTC prior to definitive repair. Findings of MRCP and PTC were compared with intraoperative details.

Results

Thirty patients with BBS were included in the study. MRCP was performed in all but PTC was amenable in 28 of 30 (93.3%) patients. PTC was comparable to MRCP in diagnosing stricture type (96.4% vs 89.3%), intrahepatic stones (75% vs 75%), and biliary anomalies (95.6% vs 100%). Additionally, PTC revealed internal biliary fistula in 4 (85.7% vs 61.4%; P value 0.04). PTC‐related minor complications were noted in 2 (7.1%) patients.

Conclusion

PTC is comparable to MRCP in diagnosing the stricture type, intrahepatic biliary stones, and biliary anomalies. Though comparable to MRCP, the authors could not reveal any additional information that could change the course of management in BBS.

Negative prognostic outcomes of percutaneous transhepatic biliary drainage in distal cholangiocarcinoma: a retrospective analysis using propensity score matching

BACKGROUND

The efficacy of different types of preoperative biliary drainage for cholangiocarcinoma has been debated over the past two decades. Controversy concerning the use of percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD) still exists. This study aimed to compare the long-term outcomes between PTBD and EBD in patients with distal cholangiocarcinoma.

METHODS

Data of patients diagnosed with distal cholangiocarcinoma who underwent preoperative PTBD or EBD from January 1999 to December 2017 were analyzed retrospectively. Post-surgical outcomes, including the incidence of post-operative complications, peritoneal metastasis, disease-free survival, and overall survival, were analyzed. Survival analyses were also performed after propensity score matching in the PTBD and EBD groups.

RESULTS

The incidence of post-operative complications was similar in both groups. The 5-year estimated cumulative incidences for peritoneal metastasis were 14.7% and 7.2% in the PTBD and EBD groups, respectively (p = 0.192). The 5-year disease-free survival rates were 23.7% and 47.3% in the PTBD and EBD groups, respectively (p = 0.015). In the multi-variate analysis for overall survival, PTBD was an independent poor prognostic factor. The 5-year overall survival rates were 35.9% and 56.3% in the PTBD and EBD groups, respectively (hazard ratio 1.85, confidence interval 1.05-3.26, p = 0.035). The results after propensity score matching indicated a poorer prognosis in the PTBD group, with a 5-year survival rate of 35.9% in the PTBD group vs 56.0% in the EBD group (p = 0.044).

CONCLUSION

PTBD should be considered as a negative prognostic factor in distal cholangiocarcinoma patients.

Diagnosis and management of hemorrhagic complications of percutaneous transhepatic biliary drainage: a primer for residents

Hemorrhagic complications are uncommon after percutaneous transhepatic biliary drainage. The presenting features include bleeding through or around the drainage catheter, hematemesis or melena. Diagnosis requires cholangiography, CT angiography or conventional angiography. Minor venous hemorrhage is managed by catheter repositioning, clamping or upgrading to a larger bore catheter. Major vascular injuries require percutaneous or endovascular procedures like embolization or stenting. A complete knowledge of these complications will direct the interventional radiologist to take adequate precautions to reduce their incidence and necessary steps in their management. This review presents and discusses various hemorrhagic complications occurring after percutaneous transhepatic biliary drainage along with their treatment options and suggests a detailed algorithm.

Percutaneous Enteral Stent Placement Using a Transhepatic Access for Palliation of Malignant Bowel Obstruction after Surgery

Objective

To assess the safety and clinical efficacy of percutaneous transhepatic enteral stent placement for recurrent malignant obstruction in patients with surgically altered bowel anatomy.

Materials and Methods

Between July 2009 and May 2019, 36 patients (27 men and 9 women; mean age, 62.7 ± 12.0 years) underwent percutaneous transhepatic stent placement for recurrent malignant bowel obstruction after surgery. In all patients, conventional endoscopic peroral stent placement failed due to altered bowel anatomy. The stent was placed with a transhepatic approach for an afferent loop obstruction (n = 27) with a combined transhepatic and peroral approach for simultaneous stent placement in afferent and efferent loop obstruction (n = 9). Technical and clinical success, complications, stent patency, and patient survival were retrospectively evaluated.

Results

The stent placement was technically successful in all patients. Clinical success was achieved in 30 patients (83.3%). Three patients required re-intervention (balloon dilatation [n = 1] and additional stent placement [n = 2] for insufficient stent expansion). Major complications included transhepatic access-related perihepatic biloma (n = 2), hepatic artery bleeding (n = 2), bowel perforation (n = 1), and sepsis (n = 1). The 3- and 12-months stent patency and patient survival rates were 91.2%, 66.5% and 78.9%, 47.9%, respectively.

Conclusion

Percutaneous enteral stent placement using transhepatic access for recurrent malignant obstruction in patients with surgically altered bowel anatomy is safe and clinically efficacious. Transhepatic access is a good alternative route for afferent loop obstruction and can be combined with a peroral approach for simultaneous afferent and efferent loop obstruction.

Role of Transarterial Embolization in the Management of Hepatic Artery Pseudoaneurysm Postlaparoscopic Cholecystectomy

Purpose To assess the safety and effectiveness of transarterial embolization (TAE) in the management of hepatic artery pseudoaneurysms following laparoscopic cholecystectomy (LC).

Materials and Methods This is a retrospective study consisting of 13 patients who had undergone TAE for management of pseudoaneurysms of the hepatic artery or its branches following LC. Patients presented with symptoms such as hypotension, hematemesis, melena or gradual anemia post LC. Abdominal CT revealed hepatic artery pseudoaneurysm in all patients. TAE was performed with either coils or N-butyl cyanoacrylate or both. We evaluated technical and clinical effectiveness and complications of TAE.

Results TAE was successful both technically and in stopping bleeding in all patients (100% technical and clinical success). No patient had rebleeding after TAE. Four patients required laparotomy for draining hemoperitoneum and clots. Endoscopic retrograde cholangiopancreatography (ERCP) for hemobilia or bile duct injury was done in eight patients. Following TAE, hepatic infarct was observed in three patients. Postembolization syndrome was seen in four patients and one patient died due to sepsis.

Conclusions TAE is effective for treatment of hepatic artery pseudoaneurysms after LC. Hepatic infarcts and postembolization syndrome are the most common complications and can be managed conservatively.

Health-Related Quality of Life evaluation in "left" versus "right" access for percutaneous transhepatic biliary drainage using EORTC QLQBIL-21 questionnaire: a randomized controlled trial

PURPOSE

To investigate the impact of the different access for percutaneous transhepatic biliary drainage (PTBD) in terms of "Quality of Life" (QoL) in the management of malignant obstructive jaundice.

METHODS

In this IRB-approved study, 64 consecutive patients with malignant obstructive jaundice were prospectively randomized to the right (group A) or left access (group B) for PTBD between February 2017 and December 2018. In order to demonstrate differences in terms of QoL between these groups, patients were asked to complete the "EORTC QLQ-BIL21" questionnaire the week after the treatment. Continuous variables were summarized by mean ± SD and compared using a Mann-Whitney U test.

RESULTS

Percutaneous transhepatic biliary drainages were performed through right access in 31 cases and 33 cases through left access. Technical success was achieved in all cases (100%). During 1 week's follow-up, there was a significant difference between group A and B in terms of pain (p < 0.001). Group A showed higher intercostal pain and respiratory difficulties compared to group B. Moreover, patients of group A showed a higher level of tiredness, anxiety, and more difficult tubes drainage and bags management than group B patients.

CONCLUSION

In our experience, the use of the questionnaires showed the right access is associated with intercostal pain and respiratory difficulties. Left access for PTBD provides a better Quality of Life for patients who underwent PTBD as palliative treatment for the management of malignant obstructive jaundice and could be considered as the approach of choice in case of distal obstruction.

Transjugular insertion of biliary stent in patients with malignant biliary obstruction complicated by ascites with/without coagulopathy: a prospective study of 12 patients

PURPOSE

In patients with malignant biliary obstruction complicated by massive ascites, when endoscopy fails, safe routes for biliary decompression are needed as an alternative to percutaneous approach. We aimed to evaluate the safety and effectiveness of transjugular insertion of biliary stent (TIBS) in patients with malignant biliary obstruction complicated by massive ascites with or without coagulopathy.

METHODS

From March 2012 to December 2017, a total of 12 consecutive patients with malignant biliary obstructions treated with TIBS were enrolled in this study. Five patients had jaundice and cholangitis, while seven had jaundice only. Clinical parameters including technical and clinical success rates and complications following TIBS were evaluated. Overall survival and stent occlusion-free survival were assessed using Kaplan-Meier analysis.

RESULTS

The indications for transjugular approach were massive ascites with (n=2) or without (n=10) coagulopathy. TIBS was technically successful in 11 of 12 patients. Clinical success was defined as successful internal drainage and was achieved in eight patients. The mean serum bilirubin level was initially 13.9±6.3 mg/dL and decreased to 4.9±5.3 mg/dL within 1 month after stent placement (P = 0.037). Two patients had procedure-related complications (hemobilia). During the follow-up period (mean, 30 days; range, 1-146 days), all 12 patients died of disease progression. The median overall survival and stent occlusion-free survival times were 19 days (95% confidence interval [CI], 16-22 days) and 19 days (95% CI, 12-26 days), respectively. There was no stent dysfunction in the eight patients that had successful internal drainage.

CONCLUSION

TIBS appears to be safe, technically feasible, and clinically effective for patients with malignant biliary obstruction complicated by massive ascites with or without coagulopathy.

RISK OF BLEEDING COMPLICATIONS IN PERCUTANEOUS BILIARY DRAINAGE: THE PARADOX OF THE NORMAL HEMOSTASIS

Background:

Percutaneous biliary drainage is a safe procedure. The risk of bleeding complications is acceptable. Frequently, patients with biliary obstructions usually have coagulation disorders thus increasing risk of bleeding. For this reason, patients should always fit the parameters of hemostasis.

Aim:

To determine whether the percentage of bleeding complications in percutaneous biliary drainage is greater in adults with corrected hemostasis prior to the procedure regarding those who did not require any.

>Methods

: Prospective, observational, transversal, comparative by independent samples (unpaired comparison). Eighty-two patients with percutaneous biliary drainage were included. The average age was 64±16 years (20-92) being 38 male and 44 female. Patients who presented altered hemostasis were corrected and the presence of bleeding complications was evaluated with laboratory and ultrasound.

Results:

Of 82 patients, 23 needed correction of hemostasis. The approaches performed were: 41 right, 30 left and 11 bilateral. The amount of punctures on average was 3±2. There were 13 (15.8%) bleeding complications, 12 (20%) in uncorrected and only one (4.34%) in the corrected group with no statistical difference. There were no differences in side, number of punctures and type of drainage, but number of passes and the size of drainage on the right side were different. There was no related mortality.

Conclusion:

Bleeding complications in patients requiring hemostasis correction for a percutaneous biliary drainage was not greater than in those who did not require any.

Primary Sclerosing Cholangitis: A Clinical Update

Primary sclerosing cholangitis (PSC) is a rare cholestatic disorder of the liver, with strictures in the bile ducts leading to cirrhosis of the liver in a proportion of patients. PSC is commonly associated with inflammatory bowel disease and increased risk of cholangiocarcinoma, gall bladder cancer, colorectal cancer, and hepatocellular carcinoma. Medical therapies are primarily aimed at symptom management and disease-modifying therapies are limited. Endoscopic therapies are used in patients with dominant strictures and liver transplantation is a last resort. In this article, the authors aim to comprehensively review the epidemiology, diagnosis, and management of PSC with emphasis on risk of malignancies and management of PSC. The authors also survey the advances in pathogenesis understanding and novel medical therapies for PSC.

RECOMMENDATIONS FOR INVASIVE PROCEDURES IN PATIENTS WITH DISEASES OF THE LIVER AND BILIARY TRACT: REPORT OF A JOINT MEETING OF THE BRAZILIAN SOCIETY OF HEPATOLOGY (SBH), BRAZILIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SOBED) AND BRAZILIAN SOCIETY OF INTERVENTIONAL RADIOLOGY AND ENDOVASCULAR SURGERY (SOBRICE)

Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato-logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.

Hemobilia: Historical overview, clinical update, and current practices

Hemobilia refers to macroscopic blood in the lumen of the biliary tree. It represents an uncommon, but important, cause of gastrointestinal bleeding and can have potentially lethal sequelae if not promptly recognized and treated. The earliest known reports of hemobilia date to the 17th century, but due to the relative rarity and challenges in diagnosis of hemobilia, it has historically not been well-studied. Until recently, most cases of hemobilia were due to trauma, but the majority now occur as a sequela of invasive procedures involving the hepatopancreatobiliary system. A triad (Quincke's) of right upper quadrant pain, jaundice and overt gastrointestinal bleeding has been classically described in hemobilia, but it is present in only a minority of patients. Therefore, prompt diagnosis depends critically on a high index of suspicion based on a patient's clinical presentation and a history of recently undergoing hepatopancreatobiliary intervention or having other predisposing factors. Treatment of hemobilia depends on the suspected source and clinical severity and thus ranges from supportive medical care to urgent advanced endoscopic, interventional radiologic, or surgical intervention. In the present review, we provide a historical perspective, clinical update and overview of current trends and practices pertaining to hemobilia.

Safety and effectiveness of ultrasound-guided percutaneous transhepatic biliary drainage: a multicenter experience

AIMS

Aim of this study is to describe a multicenter experience on percutaneous transhepatic biliary drainage (PTBD) performed with ultrasound-guidance to access the biliary tree, focusing on safety, effectiveness and radiation dose exposure; differences between right- and left-sided approaches have been also evaluated.

METHODS

This is a multicenter prospective single-arm observational study conducted on patients affected by biliary tree stenosis/occlusion with jaundice and endoscopically inaccessible. The procedures have been performed puncturing the biliary system under US guidance and crossing the stenosis/occlusion under fluoroscopy. Beam-on time and X-ray dose have been evaluated.

RESULTS

117 patients affected by biliary tree stenosis/occlusion not manageable with an endoscopic approach have been included in this analysis. The biliary stenosis/occlusion was malignant in 90.8% and benign in 9.2%. Technical success, considered as positioning of a drainage tube into the biliary tree, was 100%. Overall clinical success, considered as decrease in total bilirubin level after a single procedure, was 95.7%. The overall mean number of liver punctures to catheterize the biliary tree was 1.57. The mean total beam-on time was 570.4 s; the mean dose-area product was 37.25 Gy cm². No statistical significant differences were observed in terms of technical and dosimetry results according to right-sided and left-sided procedures. Complications rate recorded up to 30 days follow-up was 10.8%, all of minor grades.

CONCLUSIONS

In this series US guidance to access the biliary tree for PTBD was a safe and effective technique with an acceptable low-grade complications rate; the reported radiation dose is low.

Hepatic artery pseudoaneurysm following percutaneous transhepatic cholangiogram: an extremely rare complication

A 72-year-old female patient who was admitted for ischaemic stroke had developed ascending cholangitis. Percutaneous transhepatic cholangiogram was performed to drain the infected bile, but this was complicated by haemorrhagic shock and hepatic haematoma. Mesenteric angiogram showed right hepatic artery (RHA) pseudoaneurysm which was embolised, there by stopping her bleeding. RHA is normally located posterior to common bile duct (CBD). An uncommon location of RHA is anterior to CBD, which can lead to haemorrhagic complications during percutaneous cholangiogram.

Preventative care in cholestatic liver disease: Pearls for the specialist and subspecialist

Cholestatic liver diseases (CLDs) encompass a variety of disorders of abnormal bile formation and/or flow. CLDs often lead to progressive hepatic insult and injury and following the development of cirrhosis and associated complications. Many such complications are clinically silent until they manifest with severe sequelae, including but not limited to life-altering symptoms, metabolic disturbances, cirrhosis, and hepatobiliary diseases as well as other malignancies. Primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) are the most common CLDs, and both relate to mutual as well as unique complications. This review provides an overview of PSC and PBC, with a focus on preventive measures aimed to reduce the incidence and severity of disease-related complications.

Prospective Comparison of Bleeding Complications Between Right and Left Approaches in Percutaneous Biliary Drainage

PURPOSE

The present study aimed to determine whether the percentage of bleeding complications differs between the right and the left approaches in percutaneous biliary drainage (PBD) in adult patients.

MATERIALS AND METHODS

This was a prospective, descriptive, nonrandomized comparative and longitudinal study. We included adult patients over 18 years of age who underwent a PBD. We excluded those with a bilateral PBD for the comparative study. Usually, but not exclusively, we performed the right approach under fluoroscopic guidance and the left one under ultrasound and fluoroscopy.

RESULTS

Of 150 cases, 63 were performed using the right approach and 61 with the left; 26 were performed with the bilateral. The right approach faced less dilated biliary ducts and more benign diseases. We experienced 20 bleeding complications (13.33%, confidence intervals of 95%=8.3-19.8), 7 in the bilateral approach, 10 in the right approach, and 3 in the left one. The difference between the right and the left approaches was statistically significant (Fisher P=0,04). No procedures were required to obtain hemostasis, and only one patient (0.66%, confidence intervals of 95%=0.009-3.66) (in the right side) required a red blood cell transfusion. We found no related mortality.

CONCLUSIONS

Global bleeding complications are more likely to appear in the right approach in which less dilated biliary ducts and more benign diseases probably contributed to a higher number of needle passes, portal and hepatic vein punctures, and, therefore, to an increase in the risk of bleeding complications. The significant bleeding complication rate was low (0.66%).

Hemobilia: Etiology, diagnosis, and treatment☆

Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon but important cause of gastrointestinal hemorrhage. Reports of hemobilia date back to the 1600s, but due to its relative rarity and challenges in diagnosis, only in recent decades has hemobilia been more critically studied. The majority of cases of hemobilia are iatrogenic and caused by invasive procedures involving the liver, pancreas, bile ducts and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other leading causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described (i.e. Quincke's triad), but this is present in only 25%-30% of patients with hemobilia. Therefore, prompt diagnosis depends critically on having a high index of suspicion, which may be based on a patient's clinical presentation and having recently undergone (peri-) biliary instrumentation or other predisposing factors. The treatment of hemobilia depends on its severity and suspected source and ranges from supportive care to advanced endoscopic, interventional radiologic, or surgical intervention. Here we provide a clinical overview and update regarding the etiology, diagnosis, and treatment of hemobilia geared for specialists and subspecialists alike.

Hemobilia: Perspective and Role of the Advanced Endoscopist

Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon cause of gastrointestinal hemorrhage. Hemobilia has been documented since the 1600s, but due to its relative rarity, it has only been more critically examined in recent decades. Most cases of hemobilia are iatrogenic and caused by procedures involving the liver, pancreas, bile ducts, and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other major causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described, but this is present in only 25-30% of patients with hemobilia. Historically, the gold standard for diagnosis and treatment has been angiography and interventional radiologic intervention, respectively. However, the paradigm is shifting, at least in select cases, towards first-line reliance on noninvasive imaging (e.g., computed tomography) and therapeutic endoscopy, owing to advances in and the less invasive nature of both, while saving interventional radiological and/or surgical intervention for refractory or imminently life-threatening cases.

Bleeding after Percutaneous Transhepatic Biliary Drainage: Incidence, Causes and Treatments

Of all procedures in interventional radiology, percutaneous transhepatic biliary drainage (PTBD) is amongst the most technically challenging. Successful placement requires a high level of assorted skills. While this procedure can be life-saving, it can also lead to significant iatrogenic harm, often manifesting as bleeding. Readers of this article will come to understand the pathophysiology and anatomy underlying post-PTBD bleeding, its incidence, its varied clinical manifestations and its initial management. Additionally, a structured approach to its treatment emphasizing endovascular and percutaneous methods is given.

Success and complications of percutaneous transhepatic biliary drainage are influenced by liver entry segment and level of catheter placement

PURPOSE

To examine outcomes and complications of percutaneous transhepatic biliary drainage (PTBD) performed via the right or left lobe and different entry levels (lobar, segmental, subsegmental, sub-subsegmental).

METHODS

The records of patients who underwent PTBD for obstructive jaundice from 2008 to 2015 were retrospectively reviewed. Logistic regression analysis was performed to determine factors associated with outcomes and complications based on entry side and entry level. PTBD success was defined as a total bilirubin decrease after catheter placement.

RESULTS

The data of 446 patients (mean age 68.4 years) were included. Multivariate logistic regression revealed a decrease of bilirubin level was associated with left lobe (vs. right) entry [adjusted odds ratio (aOR) = 2.657, 95% confidence interval (CI) 1.160, 6.087], external drainage (aOR = 2.908, 95% CI 1.226, 6.897), and liver volume undrained <50% (aOR = 2.623, 95% CI 1.045, 6.581). PTBD success was increased with left lobe entry (aOR = 1.853, 95% CI 1.167, 2.940) and associated with entry level (subsegmental vs. lobar, aOR = 2.992, 95% CI 1.258, 7.114; sub-subsegmental vs. lobar, aOR = 3.711, 95% CI 1.383, 9.956). Complications were significantly decreased with left lobe entry (aOR = 0.450, 95% CI 0.263, 0.769) and associated with entry level (segmental vs. lobar, aOR = 0.359, 95% CI 0.148, 0.873; subsegmental vs. lobar, aOR = 0.248, 95% CI 0.10, 0.615; sub-subsegmental vs. lobar, aOR = 0.129, 95% CI 0.041, 0.411).

CONCLUSIONS

The success and complications of PTBD vary with entry side and level.

Acute Pancreatitis After Percutaneous Biliary Drainage: An Obstacle in Liver Surgery for Proximal Biliary Cancer

BACKGROUND

Percutaneous transhepatic biliary drainage (PTBD) has a crucial role in treatment of proximal biliary cancer (PBC). We assessed the incidence, risk factors, and impact of acute pancreatitis (AP) post-PTBD.

METHODS

Forty patients with PBC scheduled for PTBD from January 2005 to December 2015 were enrolled. Exclusion criteria were missing clinical data, PTBD performed in other institutions, and palliative PTBD.

RESULT

The 40 patients comprised 8 (20%) with gallbladder cancer, 6 (15%) with intrahepatic cholangiocarcinoma, and 26 (65%) with perihilar cholangiocarcinoma. A median of 1 PTBD procedure was performed per patient; 16 (40%) patients underwent PTBD more than once. PTBD was left-sided in 14 (35.0%) patients, right-sided in 21 (52.5%), and bilobar in 5(12.5%). Seventeen (42.5%) patients had one or more drainage-related complications. Five (12.5%) patients developed AP. A significantly higher percentage of patients with than without AP developed sepsis (60.0 vs. 11.4%, respectively) and did not undergo the planned liver resection [2 (40.0%) vs. 0 (0.0%), respectively]. Significantly more patients with than without AP underwent left-sided PTBD [10 (28.6%) vs. 4 (80.0%), respectively].

CONCLUSION

PTBD is frequently complicated by AP. AP plays a key role in the development of sepsis. Nearly half of patients with AP lose the opportunity for surgical treatment.

Primary Sclerosing Cholangitis: What the Gastroenterologist and Hepatologist Needs to Know

Primary sclerosing cholangitis (PSC) is a chronic, idiopathic biliary tract disease characterized by segmental strictures. The disease is progressive with no proven treatments and may eventually lead to cirrhosis and end-stage liver disease. Abrupt changes in liver biochemistries, pain, and/or cholangitis may suggest a dominant stricture amenable to endoscopic therapy or the development of cholangiocarcinoma. Patients with PSC are at increased risk of cholangiocarcinoma. There is a strong association with inflammatory bowel disease, and an associated increased risk of colorectal cancer. Colonoscopy every 1 to 2 years is appropriate.

Reduced complication rates of percutaneous transhepatic biliary drainage with ultrasound guidance

BACKGROUND

We aimed to analyze the benefits of adding ultrasound (US) guidance to the standard fluoroscopically assisted percutaneous transhepatic biliary drainage (F-PTBD). We also performed a systematic literature review of success and complication rates of US-PTBD in a wide field of indications.

METHODS

We evaluated a total of 81 US-PTBDs carried out in our institution, 74% of which were part of the management of malignancy. In addition, we compared our results with those of a total of 5,272 procedures (3,779 F-PTBD and 1,493 US-PTBD) reported in the literature.

RESULTS

US-PTBD was technically successful in 94% of attempts with a mean of 2.2 needle passes. Procedural success was achieved in 86% of cases. There were no procedure-related deaths or severe complications. Minor complications were catheter dislodgement (15%) as well as one case each of a porto-biliary fistula, hematoma, and biloma. A systematic review of the literature also showed that US-PTBD has a similar technical success rate to F-PTBD but lower median rates of severe early complications (0% versus 8%) and procedural death (0% versus 1%).

CONCLUSIONS

Given our results and our review of the literature, US-PTBD is as effective as F-PTBD and has significantly lower complication rates. US-PTBD should be preferred to F-PTBD. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:400-407, 2017.

Iatrogenic hemobilia: imaging features and management with transcatheter arterial embolization in 30 patients

PURPOSE

We aimed to evaluate the imaging features of computed tomography (CT) and angiography and the efficacy of transcatheter arterial embolization (TAE) in patients with hemobilia of different iatrogenic causes.

METHODS

Thirty patients with hemobilia were divided into two groups according to their iatrogenic causes, i.e., group 1, 11 patients (36.7%) with transhepatic intervention and group 2, 19 patients (63.3%) with surgical procedures in the hilar area. Seventeen patients (56.7%) underwent abdominal contrast-enhanced CT before selective angiography. Polyvinyl alcohol particles, gelatin sponges, and coils were used for TAE. Data from the two groups were compared using Fisher's exact test and the Mann-Whitney U test.

RESULTS

Contrast-enhanced CT showed a hematoma, extravasation of contrast material, and pseudoaneurysm. The bleeding source was determined by angiographic features in all patients, which were not significantly different between the two groups (P = 0.127), and pseudoaneurysm was the most common. The embolic material and number of coils used for TAE were significantly different between the two groups (P < 0.001), but the embolization was technically successful in all patients. The clinical success rate of the first embolization was 100% in group 1 vs. 84.2% in group 2. The overall clinical success rate of TAE was 100% in all patients. The complication rate was 63.6% in group 1 vs. 68.4% in group 2 (P = 1.000).

CONCLUSION

CT was useful in diagnosing hemobilia, and angiograms enabled determination of the bleeding source. Pseudoaneurysm was one of the most common angiographic features. TAE was successfully performed with different embolic materials on the basis of the iatrogenic cause and bleeding location.

The Complication of Hepatic Artery Injuries of 1,304 Percutaneous Transhepatic Biliary Drainage in a Single Institute

PURPOSE

To determine frequency of and assess risk factors for hepatic artery (HA) injury during percutaneous transhepatic biliary drainage (PTBD) and to discuss the technique and report the clinical outcome of embolization for HA injury.

MATERIALS AND METHODS

Over a 14-year period (2002-2016), 1,304 PTBD procedures in 920 patients were recorded. The incidence of HA injury was determined, and possible associated risk factors were analyzed. When injury occurred, HA embolization was performed at the site as close to the bleeding point as possible. Clinical outcomes of these patients after embolization were reported.

RESULTS

Of 1,304 PTBD procedures, a left-sided approach was used in 722 procedures (55.4%), and intrahepatic duct (IHD) puncture under ultrasound guidance was used in 1,161 procedures (90.1%). The IHD was nondilated in 124 (9.5%) patients. The punctured ductal entry site was peripheral in 1,181 (90.6%) patients. In this series, 8 procedures (0.61%) were complicated by HA injury. IHD dilatation status was the only risk factor (P = .017) for HA injury. Embolization was performed with technical and clinical success in all 8 patients. No recurrent hemobilia, intraabdominal bleeding, or other sequelae of HA injury after embolization was noted during 1 week to 84 months of follow-up.

CONCLUSIONS

HA injury is a relatively rare complication of PTBD. IHD dilatation status was the only risk factor for HA injury in this study. When HA injury occurred, embolization therapy was effective in managing this complication.

Hemobilia following laparoscopic cholecystectomy: computed tomography findings and clinical outcome of transcatheter arterial embolization

BACKGROUND

Hemobilia following laparoscopic cholecystectomy (LC) can occur in the early or late postoperative course and poses a diagnostic and therapeutic challenge.

PURPOSE

To assess computed tomography (CT) findings and clinical outcomes after transcatheter arterial embolization (TAE) in patients presenting with hemobilia following LC.

MATERIAL AND METHODS

Fourteen patients treated for hemobilia following LC were included in the study. Three patients were diagnosed by endoscopy and 11 by abdominal contrast-enhanced CT. Coils or microcoils were superselectively deployed to occlude the bleeding vessel during TAE. Abdominal CT findings of hemobilia, and the success rate and complication of TAE were observed.

RESULTS

Abdominal CT provided the following signs of hemobilia: hematoma within the abdominal cavity and gallbladder fossa, blood clots containing high attenuation within the bile duct, biliary dilatation, pseudoaneurysm of the right hepatic artery, contrast extravasation, enhancement of the bile duct wall, and hypoperfusion of the right lobe. The success rate of TAE was 100% and rebleeding did not occur in any patient. Post-embolization syndrome and hepatic ischemia occurred in nine patients, which was associated with age and the time interval between the LC and TAE.

CONCLUSION

Abdominal CT provided direct signs that can aid in the diagnosis of hemobilia after LC. TAE allowed for successful treatment of hemobilia with minor complications.

Imaging findings and endovascular management of iatrogenic hepatic arterial injuries

Iatrogenic hepatic arterial injuries (IHAIs) include pseudoaneurysm, extravasation, arteriovenous fistula, arteriobiliary fistula, and dissection. IHAIs are usually demonstrated following percutaneous transhepatic biliary drainage, percutaneous liver biopsy, liver surgery, chemoembolization, radioembolization, and endoscopic retrograde cholangiopancreatography. The latency period between the intervention and diagnosis varies. The most common symptom is hemorrhage, and the most common lesion is pseudoaneurysm. Computed tomography angiography (CTA) is mostly performed prior to angiography, and IHAIs are demonstrated on CTA in most of the patients. Patients with IHAI are mostly treated by coils, but some patients may be treated by liquid embolic materials or stent-grafts. CTA can also be used in the follow-up period. Endovascular treatment is a safe and minimally invasive treatment option with high success rates.

The safety and efficacy of nasobiliary drainage versus biliary stenting in malignant biliary obstruction: A systematic review and meta-analysis

BACKGROUND

Preoperative biliary drainage (PBD) has been widely used to treat patients with malignant biliary obstruction. However, it is still unclear which method of PBD (endoscopic nasobiliary drainage or endoscopic biliary stenting) is more effective. Thus, we carried out a meta-analysis to compare the safety and efficacy of endoscopic nasobiliary drainage (ENBD) and endoscopic biliary stenting (EBS) in malignant biliary obstruction in terms of preoperative and postoperative complications.

METHODS

We conducted a literature search of EMBASE databases, PubMed, and the Cochrane Library to identify relevant available articles that were published in English, and we then compared ENBD and EBS in malignant biliary obstruction patients. The preoperative cholangitis rate, the preoperative pancreatitis rate, the incidence of stent dysfunction, the postoperative pancreatic fistula rate, and morbidity were analyzed. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to express the pooled effect on dichotomous variables, and the pooled analyses were performed using RevMan 5.3.

RESULTS

Seven published studies (n = 925 patients) were included in this meta-analysis. We determined that patients with malignant biliary obstruction who received ENBD had reductions in the preoperative cholangitis rate (OR = 0.35, 95% CI = 0.25-0.51, P < 0.0001), the postoperative pancreatic fistula rate (OR = 0.38, 95% CI = 0.18-0.82, P = 0.01), the incidence of stent dysfunction (OR = 0.39, 95% CI = 0.28-0.56, P < 0.0001), and morbidity (OR = 0.47, 95% CI = 0.27-0.82, P = 0.008) compared with patients who received EBS.

CONCLUSIONS

The current meta-analysis suggests that ENBD is better than EBS for malignant biliary obstruction in terms of the preoperative cholangitis rate, the postoperative pancreatic fistula rate, the incidence of stent dysfunction, and morbidity. However, a limitation is that there are no data from randomized controlled trials.

Radiological interventions in malignant biliary obstruction

Malignant biliary obstruction is commonly caused by gall bladder carcinoma, cholangiocarcinoma and metastatic nodes. Percutaneous interventions play an important role in managing these patients. Biliary drainage, which forms the major bulk of radiological interventions, can be palliative in inoperable patients or pre-operative to improve liver function prior to surgery. Other interventions include cholecystostomy and radiofrequency ablation. We present here the indications, contraindications, technique and complications of the radiological interventions performed in patients with malignant biliary obstruction.

Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction

AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.

METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent (PS) or nasobiliary catheter (NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedure-related adverse events, stent/catheter dysfunction (occlusion or migration of PS/NBC, development of cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution (bilirubin level < 3.0 mg/dL) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.

RESULTS: In total, 419 patients were included in the study (PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients (46%), bile duct cancer in 172 (41%), gallbladder cancer in three (1%), and ampullary cancer in 50 (12%). The median serum total bilirubin was 7.8 mg/dL and 324 patients (77%) had ≥ 3.0 mg/dL. During the median time to surgery of 29 d [interquartile range (IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio (SHR) = 4.76; 95%CI: 2.44-10.0, P < 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method (PS or NBC).

CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.