Background
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 Transcutaneous Cholangiography, and Biliary Stenting.
Indications
In many cases, PTC is followed by the placement of percutaneous biliary catheters for drainage. PBD is needed in many patients. For example, it may be helpful in relieving obstructive symptoms, especially those due to unresectable malignant tumors [5] (see the image below), though its value in the setting of malignant biliary obstruction has been questioned by some. [6] PBD may also be helpful in treating those with various types of benign strictures (including postoperative strictures), primary sclerosing cholangitis and liver transplants. [7]
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 PBD being reserved for conditions in which ERCP fails [8] or is not available.
In a study of 13 patients with biliary obstruction of unknown origin, Augustin et al found that PBD-based forceps biopsy via the transhepatic drainage tract was technically feasible and safe, with good diagnostic value rates. [9] They suggested that this procedure should be considered in patients not suitable for endoscopic strategies.
Contraindications
Contraindications for PBD include the following [10] :
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Massive ascites
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Multiple intrahepatic obstructions
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Bleeding diathesis
Outcomes
A systematic review and meta-analysis by Facciorusso et al compared PBD with surgical hepaticojejunostomy, endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CD), and EUS-guided hepaticogastrostomy (EUS-HG) as methods for draining distal malignant biliary obstruction after failed ERCP. [11] The primary outcome was clinical success; secondary outcomes were technical success and adverse event rate. None of the tested methods could be shown to be superior to the others, though there was a trend toward increased rates of adverse events (in particular, bleeding events) with PBD.
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Obstruction of the common bile duct in a patient with pancreatic carcinoma.
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A stiff wire is advanced to the small bowel and used to advance the biliary catheter to the small bowel.
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Internal-external biliary drain in a patient with obstruction of the common bile duct (CBD).
