Percutaneous Biliary Drainage
- Author: Altaf Dawood, MBBS, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR more...
Over the past few decades, biliary interventions have evolved a great deal. Opacification of the biliary system was first reported in 1921 with direct puncture of the gallbladder. Subsequent reports described direct percutaneous biliary puncture. The technique was revolutionized in 1960s with the introduction of fine-gauge (22- to 23-gauge) needles.
During the 1970s, percutaneous biliary drainage (PBD) for obstructive jaundice and percutaneous treatment of stone disease was introduced.[1, 2] Percutaneous cholecystostomy was first described in the 1980s. With the advent of metallic and plastic internal stents, further applications in the treatment of biliary diseases were developed.
Current percutaneous biliary interventions include percutaneous transhepatic cholangiography (PTC) and biliary drainage to manage benign and malignant obstruction and percutaneous cholecystostomy. Percutaneous treatment of biliary stone disease with or without choledochoscopy is still performed in selected cases. Other applications include cholangioplasty for biliary strictures, biopsy of the biliary duct, and management of complications from laparoscopic cholecystectomy and liver transplantation.
This article outlines the procedure for percutaneous biliary drainage. For descriptions of other biliary interventions, see Percutaneous Cholecystostomy, Percutaneous Cholangiography, and Biliary Stenting.
In many cases, percutaneous transhepatic cholangiography (PTC) is followed by the placement of percutaneous biliary catheters for drainage. Percutaneous biliary drainage (PBD) is needed in many patients. For example, it may be helpful in relieving obstructive symptoms, especially those due to unresectable malignant tumors (see the image below), as well as in treating those with various types of benign strictures (including postoperative strictures), primary sclerosing cholangitis and liver transplants.
Other indications include cholangitis secondary to biliary obstruction, diversion for bile leaks while the patient is awaiting surgery, and transhepatic brachytherapy for cholangiocarcinoma.
Nowadays, endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of therapy for the above conditions, with percutaneous biliary drainage being reserved for conditions in which ERCP fails or is not available.
Contraindications for percutaneous biliary drainage include the following :
Multiple intrahepatic obstructions
The patient is placed in a supine position, and sterile preparation and draping are performed.
Percutaneous transhepatic cholangiography (PTC) is performed (see Percutaneous Cholangiography). Once the needle is in the bile duct, a 0.018-in. wire is advanced. After the wire is passed to a secure position in the biliary tree, the needle is removed. For further interventions, a larger (eg, 0.035- or 0.038-in.) wire is needed. A sheath of the coaxial system can be passed over the 0.018-in. wire, and the inner two components (wire and inner coaxial dilator) can then be removed to accept the larger wire.
The assembly set, consisting of an outer fluoropolymer sheath (Teflon; DuPont, Wilmington, DE), an inner fluoropolymer sheath (Teflon; DuPont), and a metal cannula, is advanced over the wire. The two sets in common use are the Accustick introduction system (Meditech/Boston Scientific; Watertown, MA) and the Neff percutaneous access set (Cook, Inc; Bloomington, IN).
After the tip is in the bile duct, the two outer fluoropolymer sheaths are advanced over the wire. Once the sheaths are in position, the inner sheath and stiffener are removed, leaving the outer sheath behind. This outer sheath has a 4-French inner diameter and a 4-French catheter through which a 0.035- or 0.038-in. wire can be passed.
Cholangiography with further injection of contrast agent can be performed at this stage to improve delineation of the level of obstruction.
A 4-French catheter with a distal curve (eg, Berenstein catheter) and a 0.035-in. hydrophilic guide wire are usually used to cross the obstructing lesion. When the obstruction is high-grade and the bile ducts are severely dilated, crossing the obstruction may not be possible. In these cases, external drainage can be tried for a few days to decompress the biliary system, and another attempt can be made later.
After the catheter is advanced to the duodenum, the wire is exchanged for a stiff guide wire (eg, Amplatz superstiff wire; Cook, Inc) (see the image below). The catheter and sheath are removed, and a biliary drainage catheter is advanced.
Various biliary drainage catheters are available. Commonly used catheters have a retaining pigtail loop. The end of this catheter is reformed after the catheter tip is in position in the duodenum and after the inner stiffener is removed (see the image below). The proximal side-hole location is checked by injecting contrast material to ensure that it is in the bile duct and not intraparenchymal; malpositioning may lead to pericatheter leakage or hemobilia. The internal fixation is achieved by using a loop-retaining suture.
Catheters are also secured to skin by using suture material such as 2-0 polypropylene mesh. The catheter should initially be left to external gravity drainage. A cap can be placed after a few days when the bile is clear of blood and when the patient is afebrile.
Patients should be instructed regarding routine catheter care if they are being discharged home after the procedure. The catheter should be flushed with 5-10 mL of sterile water or normal sodium chloride solution at least every 24 hours to prevent debris collection and catheter blockage. Catheters should be exchanged every 3-4 months because they are prone to breakage and occlusion over time. Some authors advocate exchange even more frequent than this.
Patients should be instructed to uncap the catheter to set it for external drainage in case of the onset of fever. If fever occurs, further investigation is usually necessary because it is presumed to be due to catheter blockage and resultant cholangitis until proven otherwise.
Alternatives to standard drainage
Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an effective alternative for biliary drainage after a failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-BD can be divided into three different techniques as follows:
EUS-ERCP rendezvous technique
EUS-guided antegrade biliary drainage
EUS-guided transluminal biliary drainage
Complications of percutaneous drainage are most frequent in cases of malignant obstruction. In addition to complications of percutaneous transhepatic cholangiography (PTC), bile leakage, bilorrhea, hemobilia, cholangitis, hemothorax, and pancreatitis can develop. For more information on the complications of PTC, see Percutaneous Cholangiography.
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