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Percutaneous Biliary Drainage

  • Author: Altaf Dawood, MBBS, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR  more...
 
Updated: Nov 11, 2014
 

Overview

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[3] 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.[4] For descriptions of other biliary interventions, see Percutaneous Cholecystostomy, Percutaneous Cholangiography, and Biliary Stenting.

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Indications

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.[5]

Obstruction of the common bile duct in a patient w Obstruction of the common bile duct in a patient with pancreatic carcinoma.

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.

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Contraindications

Contraindications for percutaneous biliary drainage include the following[35] :

  • Massive ascites
  • Multiple intrahepatic obstructions
  • Bleeding diathesis
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Technique

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.

A stiff wire is advanced to the small bowel and us A stiff wire is advanced to the small bowel and used to advance the biliary catheter to the small bowel.

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.

Internal-external biliary drain in a patient with Internal-external biliary drain in a patient with obstruction of the common bile duct (CBD).

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).[36] 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
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Complications

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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Contributor Information and Disclosures
Author

Altaf Dawood, MBBS, MD Chief Medical Resident and Clinical Instructor, Department of Internal Medicine, University of Nevada School of Medicine

Altaf Dawood, MBBS, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Vijay Jayaraman, MD Assistant Professor of Medicine, Division of Gastroenterology, University of Nevada School of Medicine

Vijay Jayaraman, MD is a member of the following medical societies: American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Medical Society of the State of New York, New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Douglas M Coldwell, MD, PhD Professor of Radiology, Director, Division of Vascular and Interventional Radiology, University of Louisville School of Medicine

Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Heart Association, SWOG, Special Operations Medical Association, Society of Interventional Radiology, American Physical Society, American College of Radiology, American Roentgen Ray Society

Disclosure: Received consulting fee from Sirtex, Inc. for speaking and teaching; Received honoraria from DFINE, Inc. for consulting.

Chief Editor

Kyung J Cho, MD, FACR, FSIR William Martel Professor of Radiology, Interventional Radiology, University of Michigan Health System, Frankel Cardiovascular Center

Kyung J Cho, MD, FACR, FSIR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Additional Contributors

Gary P Siskin, MD Professor and Chairman, Department of Radiology, Albany Medical College

Gary P Siskin, MD is a member of the following medical societies: American College of Radiology, Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North America

Disclosure: Nothing to disclose.

Acknowledgements

Author: Altaf Dawood, MBBS, MD, Chief Medical Resident and Clinical Instructor, Department of Internal Medicine, University of Nevada School of Medicine.

Altaf Dawood is a member of the following medical societies: American College of Physicians.

Coauthor(s): Vijay Jayaraman, MD, Assistant Professor of Medicine, Division of Gastroenterology, University of Nevada School of Medicine.

Disclosure: Nothing to disclose.

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Obstruction of the common bile duct in a patient with pancreatic carcinoma.
A stiff wire is advanced to the small bowel and used to advance the biliary catheter to the small bowel.
Internal-external biliary drain in a patient with obstruction of the common bile duct (CBD).
 
 
 
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