Biliary Intervention – Flashcards

RHD: drains segments 5-8 -Formed by right posterior duct (RPD) and right anterior duct (RAD). -RAD: drains segments 5 and 8, and has a more vertical course on AP cholangiographic images -RPD: drains segments 6 and 7, and has a more horizontal course. -Normally, the RPD passes behind the RAD and joins the RAD on its medial side to form the RHD

LHD: usually horizontally oriented in the left lobe of the liver -Drains segments 2-4 -Joins the RHD to form the CHD, and exits liver at biliary hilum -CHD is joined by cystic duct to form CBD.

Standard anatomy in 57%, with wide # of variations. -Variations that most affect biliary drainage involve anomalous drainage of the RPD and RAD -The RPD may drain into the LHD (16%) close to the hilum or at some distance from the hilum (5%). -Less commonly the RHD can drain into the LHD. -Occasionally the RAD, RPD, and LHD form a triple confluence, so there is no RHD. -In patients with hilar obstruction with anomalous drainage of RPD into the LHD, left-sided drainage drains most of the liver. -Often, if the RPD drains anomalously into the LHD, a very acute angle may be formed by junction of the RPD with the LHD, making passage of wires/catheters difficult.

Antibiotic prophylaxis is mandatory -Common regimens include zosyn (piperacillin/tazobactam) 4.5 g IV, gentamicin 80 mg IV, and ampicillin 1 g IV. -Zosyn is broad-spectrum with activity against gram-+, gram-neg, and aerobic infections, with high levels in bile. -For biliary drainage, it is common to continue treatment for 2 days tid with zosyn. In jaundiced patients with malignant obstruction, IV fluids are often started before procedure, and continued for 3-4 days, commonly 2.5 L of Hartman's solution daily.

Failed endoscopic drainage Hilar obstruction Biliary problems after biliary enteric anastomoses Injury after lap chole

Diagnostic PTC performed predominantly from right side -Patient asked to take a deep breath under fluoro, and the position of maximal lung descent is marked. Point of needle access chosen 1-2 interspaces below this point in the mid-axillary line. -22-g Chiba needle (15 cm) is inserted under fluoro from the right flank toward the T12 vertebral body. It is inserted parallel to tabletop in one smooth motion. -Stylet withdrawn and small aliquots of CM are injected every 1-2 mm until a bile duct is entered. -If a bile duct isn't entered on the first pass, successive passes are made in a fan shape down through the liver toward the biliary hilum, taking care not to withdraw the needle fully outside the liver capsule. -When bile duct is entered, contrast is injected via extension tube. -With low bile duct obstructions, it is helpful to tilt the table. -Images obtained in AP and both oblique positions.

Bile duct: contrast material flows away from the tip slowly, akin to wax flowing down a candlestick -Hepatic vein: contrast washes quickly away toward the heart -Portal vein: contrast washes quickly away toward the periphery of the liver.

Procedure is best terminated after 15-20 failed passes with the needle. -Alternatively, one can place a needle into the GB and inject contrast through the GB to outline the biliary system. -This is only possible if the biliary obstruction is below the junction of the cystic duct and CHD. If blood coagulation parameters are abnormal, the perc tract can be embolized with Gelfoam or autologous blood clot as the needle is withdrawn.

One-stick needle system commonly used for access. -When a bile duct (BD) is entered, contrast in inject to opacify biliary system. If patient is septic, the minimum amount of CM is injected. -If a favorable duct is entered, a 0.018 inch guidewire is placed through needle and manipulated toward the hepatic hilum and CBD. -For patients with hilar obstruction, it is important to gain entry into a peripheral duct, particularly if a stent will be placed. -If the wire doesn't run appropriately down the duct toward the hilum, you can turn the bevel of the needle in 90-degree aliquots and then probe with the wire. -When the 0.018 wire is at the level of the CHD or more distally, the needle is withdrawn and replaced with a 5-Fr sheath assembly. -Particularly with a vertical BD, the metal stiffening cannula should be removed when the sheath assembly reaches the BD, allowing the more flexible inner 4-Fr plastic cannula and 5-Fr sheath to follow the guidewire down toward the hilum. -A 0.035 hydrophilic guidewire or 1.5-mm J guidewire can also be used to manipulate down the duct.

Once good purchase is obtained, the 4-Fr inner plastic cannula and 0.018 guidewire are removed -A 0.035 or 0.038 in J-guidewire is placed through the 5-Fr sheath into the biliary tree. -The 5-Fr sheath is removed -A hockey-stick type catheter is placed over the J-wire -J-wire exchanged for a 0.035 in hydrophilic guidewire with a straight tip -The hockey-stick catheter and glidewire are manipulated down to a level just above the stricture. -Glidewire is removed and contrast is injected, often showing a small nipple of compressed duct above the stricture. -Stricture is probed with the hydrophilic guidewire until it is crossed. -Hockey-stick catheter advanced through stricture over the hydrophilic guidewire, and both are then manipulated into the proximal jejunum.

The hydrophilic guidewire is exchanged for a 0.035 inch superstiff guidewire before tract dilatation. -Tract through liver is dilated with a 7-Fr dilator and a 9-Fr peel-away sheath. -If the lesion is not appropriate for stenting, an internal/external biliary drainage catheter is placed, commonly an 8.3-Fr Ring catheter with 32 or 42 side-holes (32 for low CBD obstruction, 42 for hilar obstruction). -The peel-away sheath protects liver parenchyma, prevents buckling of guidewire and catheter in the perihepatic space, and helps direct the pushing force applied to the catheter down the BD. -The Ring catheter is placed well into the duodenum, and the guidewire is removed. CM is injected and the catheter withdrawn until CM is seen to opacify the biliary tree proximal to the obstruction, implying that there are catheter side-holes above and below the level of obstruction. -Catheter placed to gravity drainage and attached to a bag.

Left-sided biliary drainage is typically performed when the patient has a hilar stricture, and may be more technically challenging. -Segment-3 BD usually chosen for entry. It courses inferiorly toward the inferior margin of the left lobe. -If the patient has a large enough left lobe, it may permit access of a segment-2 duct, which has a more horizontal course in the left lobe, offering the advantage of a more gentle curve with less acute angle. -For patients with hilar obstruction, it is important to gain access to the left biliary system in as peripheral a location as the anatomy allows. -22-g Chiba needle used to access the segment 2 or 3 duct, and contrast is injected to outline biliary system. -0.018 wire is manipulated toward hilum, followed by the 5-Fr sheath system as on the right. -The hydrophilic guidewire and Kumpe catheter are used to negotiate the stricture and placed in proximal jejunum. -Tract dilated over a 0.035 in superstiff guidewire. -9-Fr sheath is particularly important for access of a segment-3 duct because it helps direct the pushing force down the CBD, making catheter placement easier.

Metallic biliary stents are preferred over plastic stents: -Require significantly less track dilatation than do plastic stents (7-Fr vs. 10-12 Fr) -They can be placed at same time as initial drainage procedure -Shorter hospital stays -More cost-effective than plastic stents.

Stage 1: tumor involves the CHD, > 2 cm from biliary hilum Stage 2: tumor involves biliary hilum and the right and left HD. Stage 3a: tumor grows out along the RHD with involvement of right segmental ducts Stage 3b: tumor encases the LHD and involves left segmental ducts. Stage 4: segmental involvement in both left and right hepatic lobes.

Principle of palliation : drain as much of functioning liver as possible. -Optimal palliation for hilar malignancies (usually Klatskin tumor) is achieved when both sites are stented. -Anomalous drainage of RPD into the LHD: draining the left lobe alone may be sufficeint. -Separate occlusion of the RAD and RPD (stage 3a): draining the right side is of little benefit. Draining the left side alone if it is of adequate size may be beneficial.

Most popular metallic biliary stent is the Wallstent -Self-expanding stainless steel mesh -Preferred length for biliary tree is 9 cm, with 1 cm diameter. -Flexible delivery system with small delivery catheter (7-Fr). -Stent has a large luminal diameter (1 cm) -The stent deploys from distal to proximal, and tends to move forward a little as it deploys. It is thus important to reposition the delivery catheter during stent deployment. Gianturco is the 2nd most popular Covered stents can also be used in the lower CBD rather than the hilum so that side branches are not covered.

Common approach: bilateral deployment of Wallstents in a Y-configuration. Principles of effective palliation for hilar strictures: -Peripheral purchase within biliary tree -Overstenting (proximal end of stent is situated at least 2-3 cm above the proximal edge of the tumor). Deploying stents: -2 0.035 inch superstiff guidewires are placed across the stricture into the duodenum. -Stents are loaded on each wire in turn and placed across the stricture from right and left sides. -Stents positioned with 2-3 cm of stent above tumor, and deployed. -The track is often embolized with Gelfoam or a mixture of glue and lipiodol. -If there is significant hemobilia or sepsis, a safety catheter is left through both sides for 2-3 days. -Usually don't dilate the stents in situ unless you aren't leaving a safety catheter. If no catheter, then the stent is dilated in the area of the stricture using an 8-mm balloon to speed up the self-expanding process. The Wallstent tends to expand and shorten over time.

Correct catheter fixation to skin is important: -Especially for right-sided catheter, if it is tied too tightly at skin entry site, the catheter is not free to move with the liver as the patient breaths, and tends to back out of the liver with breathing, forming a loop between the liver capsule and the abdominal wall. -This can lead to drainage problems such as backbleeding through the catheter if a side-hole migrates back into the liver and communicates with a vein. -Side-hole may also migrate outside of liver and communicate with pleural space or abdominal cavity, causing bile leak. -To avoid these problems, allow ~ 2 cm of slack in the catheter when suturing it to the skin. Catheter irrigated with saline every 6 hours for first 48 hours. -Kept on zosyn tid for 2-3 days, and maintain IV fluids.

Hemobilia: occurs frequently, but is almost always transient, settling over 2-3 days. -Backbleeding can occur if catheter side-hole is left in the hepatic parenchyma and communicates with a hepatic vein. Can be repositioned. -FFP may need to be given after procedure due to short half-life. -Hemobilia presenting after several days of drainage is usually more serious, and may be due to pseudoaneurysm or tumor bleeding. Replacing the catheter with a larger catheter often tamponades bleeding from a PsA, but embo may be needed. Bacteremia -Continue Abx for 2 days after drainage. -For patients who are septicemic before the procedure, it is best to perform the procedure with the minimum intervention necessary. -The biliary tree shouldn't be overdistended with contrast. It may be appropriate to simply place an external drain rather than internal/external. Bile leak and peritonitis: -Important during drainage that dilators and catheters not be removed until the next dilator or catheter is ready to be placed. If the track has been dilated and only the guidewire is present in the track, bile can flow out along the guidewire into the peritoneal cavity. -Using a 9-Fr sheath helps protect peritoneal cavity from bile leaks. -Embo of the track with Gelfoam or glue helps prevent bile leakage and bleeding. Late complications of stents include occlusion and tumor ingrowth. Migration is rare with metallic stents.

-Patient with septicemic shock due to cholangitis, in whom the minimum intervention necessary to drain the patient is appropriate. -Patient with a BD stricture or transection at lap chole. External drainage helps temporize patient before definitive surgery. -Catheter needs to have a relatively small pigtail with relatively large side-holes to promote biliary drainage. -5 or 7-Fr angiographic pigtail catheter is not appropriate because it doesn't drain well and tends to fall out. -8-Fr locking pigtail catheter designed for perc chole is often useful.

Long-term int/ext biliary drainage catheters may be used after balloon dilatation of anastomotic strictures and in patients with duodenal encasement from pancreatic carcinoma where a metal stent can't be placed. Usually a 10 or 12-Fr catheter rather than the 8.3 Fr Ring catheter placed at initial biliary drainage. -When the 12-Fr catheter is palced, it is left to free drainage for 1-2 days and then clamped as long as patient is afebrile. If patient tolerates clamping, he/she can be discharged. -Catheter needs replacement every 2-3 months, or sooner if catheter occlusion or fever occurs.

If patient is septic, drain immediately The other determining factor is whether CM was injected above the level of the obstruction during failed ERCP. -If not CM injected and patient not septic, PTC can be performed within 2 days. -If CM was injected above the obstruction, start IV fluids and perform PTC within 8-12 hours.

Important to delineate anatomy by PTC or prior imaging. Define the site and nature of bile duct -If the bile duct is intact and there is leakage only from the cystic duct stump, then ERCP is appropriate. -If bile duct has been injured and there is associated leakage, then drainage and stenting are best performed percutaneously. -In setting of bile duct ligation (often due to aberrant biliary anatomy), the intrahepatic BDs can be drained with an external biliary drainage catheter placed above the level of the ligation. Any associated leakage can be drained percutaenously. The patient will return weeks later for definitive reconstruction.

Average patency rate for metallic stents in the biliary tree is ~ 6 months. Causes: -Tumor overgrowth at upper or lower end of stent -Tumor ingrowth through the wire mesh of the stent -Occlusive debris clogging the stent. Overgrowth: prevented by overstenting -For tumor overgrowth above the stent, PTC can be performed and a guidewire manipulated through stent into duodenum. -The tumor above the stent can be dilated, and a second Wallstent inserted in a sleeved fashion through the 1st Wallstent. Tumor ingrowth: -Can be managed with balloon dilatation of the 1st stent in the region of tumor ingrowth, followed by placement of a 2nd stent. Stent occlusion with debris or sludge: -Can be managed by manipulated a guidewire down through the lumen of the occluded stent and using a balloon catheter to sweep the stent clear of debris. ERCP can also be used for stent occlusion.

-Balloon dilatation of biliary strictures is most often performed in patients with anastomotic strictures such as choledochojejunal or hepaticojejunal anastomoses. -Patients with iatrogenic strictures of bile ducts are also suitable candidates (limited data shows better results for surgery in these patients) -Patients with PSC may benefit from dilatation as long as there is a dominant stricture. Lower success rate, but balloon dilatation may be the only available treatment, particularly for intrahepatic ductal strictures. -Biliary strictures from pancreatitis or biliary calculi can be dilatated, but these are usually done via ERCP.

-Appropriate broad-spectrum Abx prophylaxis -Baseline serum alkaline phosphatase- most sensitive indicator of anastomotic stricture formation. -MRC useful for diagnosis and planning. -Liberal sedoanalgesia. -When planning a retrograde access through a jejunal Roux loop, CT is useful to ascertain the location of the Roux loop and position of the colon relative to the loop.

-Traditional method is transhepatic access with dilatation of a track through the liver parenchyma with placement of a balloon catheter across the stricture site. -A less traumatic access is the use of retrograde access through a Roux loop. Some surgeons when fashioning the Roux loop for hepaticojejunostomy or choledochojejunostomy fix a portion of the Roux loop anteriorly underneath the abdominal wall. Clips or a metallic ring mark the site for access of the loop with wires/catheters placed retrograde though the loop into the intrahepatic biliary tree. -Even if surgeon hasn't fixed the Roux loop underneath the anterior abdominal wall, the loop can still be used for retrograde access. A transhepatic cholangiogram is first performed and contrast injected. When contrast enters the loop, it can be punctured under fluoro and used for biliary access.

It can occasionally be difficult to determine whether there is some evidence of narrowing at the anastomotic site. -Biliary manometry is used by some, but this is cumbersome and difficult to interpret. -Instead, you can place a 10-mm balloon across the anastomosis and inflate the balloon. Presence of stricture is determined by the presence of a waist in the balloon. The balloon is inflated until the waist disappears. The balloon should be inflated for 2-3 minutes and repeated until the waist disappears. Often the waist on a 10-mm balloon is minimal, so a 12-mm balloon can then be used.

Role of long-term stenting of the dilated stricture is controversial. Some advocate leaving a long-term stent across the anastomosis for 6-12 months -Authors (Requisites) prefer to leave a 10-12 Fr soft catheter (Cope Loop, Cook) across the stricture/anastomosis for 3-4 weeks. The patient returns for cholangiogram. If anastomosis appears widely patient, the catheter is removed. If anastomosis isn't patent, balloon dilatation is repeated and the catheter left for another 3-4 weeks.

Metallic stents should be used as a last resort when benign biliary strictures fail to respond to balloon dilatation -Authors (Requisites) perform at least 3 separate dilatation procedures before resorting to metallic stenting. -For young patients, surgical revision may be best option after failed PTA. Stenting may be appropriate for older patients. -If it is decided to place metallic stent, then a Gianturco-Rosch stent should be placed rather than a Wallstent. The Gianturco-Rosch stent exerts a stronger radial force and presents a lesser surface area for development of intimal hyperplasia. It is thus the preferred stent for dealing with recalcitrant biliary strictures.

ERCP may be unsuccessful in removing stones due to previous gastric surgery, a large diverticulum at the ampulla of Vater, or other technical problems. -If ERCP is unsuccessful, a rendezvous procedure can be used to remove or manage CBD stones. -Standard biliary drainage is performed and an internal/external biliary drainage catheter is left in the duodenum. After 1-2 days, ERCP is performed to permit access for endoscopic bile duct cannulation and stone removal. If rendezvous procedure isn't possible due to altered upper GI anatomy, alternatives include open surgical or transhepatic removal of CBD stones. -Transhepatic approach can be used to perform a sphincteroplasty by inflating a 10-mm balloon across the sphincter of Oddi and pushing small stones into the duodenum with a semi-inflated balloon. -Transhepatic stone removal is rarely performed because it requires a mature tract through the liver. This involves initial PTC and sequential tract dilatation, followed by basket extraction of stones or mechanical lithotripsy.

If patient has a post-op T-tube in place, then ERCP is inappropriate because any retained stones can be removed easily through the percutaneous tract. -If stone removal through the T-tube tract is planned, the T-tube is left in situ for 4-6 weeks until a mature tract develops. -Patient returns for stone removal with standard abx prophylaxis. -T-tube cholangiogram performed to confirm that the stones are still present. If they are not present, the tube can be removed.

-T-tube removed over guidewire and access to duodenum achieved using a combination of a hydrophilic wire and Kumpe catheter. -Superstiff wire placed in duodenum and left as a safety-wire. -A steerable catheter (Burhenne) is placed in the bile duct through the T-tube tract. The handle of the Burhenne is used to deflect the tip of the catheter so that the catheter can be manipulated either up or down the bile duct, depending on where the stone is located. -The Burhenne catheter is placed a little distal to the stone and a basket placed through the catheter. The basket is opened distal to the stone, and the catheter and basket are slowly withdrawn until the stone is reached. -The catheter and basket are jiggled so that stone falls within basket. The basket is then pulled back against the end of the Burhenne catheter to grip the stone, and the catheter and basket are removed as a unit. -If the stone is too large to be removed from the tract, the stone can be fragmented by electrohydraulic, laser, or mechanical lithotripsy. -After the procedure, if significant edema is present at the ampulla, a 12-Fr catheter is left in the duodenum for 2-3 days. No catheter is left for an atraumatic procedure.