Percutaneous Biliary Drainage

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.

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 for PBD include the following[10] :

• Massive ascites
• Multiple intrahepatic obstructions
• Bleeding diathesis

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.

Antibiotic prophylaxis is provided in accordance with current guidelines.[12]

The patient is placed in a supine position. Sterile preparation and draping are performed. 

Percutaneous biliary drainage (PBD) begins with the performance of percutaneous transhepatic cholangiography (PTC). 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 allow passage of 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. Two sets in common use are the Accustick introduction system (Meditech/Boston Scientific, Watertown, MA) and the Neff percutaneous access set (Cook, 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 a contrast agent can be performed at this stage to improve delineation of the level of obstruction. Bile should be aspirated to decompress the bile duct before injection of contrast medium for a cholangiogram.

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). (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 exchanging catheters even more frequently 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).[13, 14, 15, 16]  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

EUS-BD has been performed in combination with ERCP in an effort to reduce recurrent biliary obstruction.[17]

Complications of PBD are most frequent in cases of malignant obstruction. In addition to complications of PTC, bile leakage, bilorrhea, hemobilia,[18] cholangitis, hemothorax, and pancreatitis can develop.

Some investigators have found that the addition of ultrasonography (US) to guide the procedure lowers complication rates.[19] In a study comparing fluoroscopically guided PBD with US-guided PBD, Nennstiel et al found that whereas overall complication rates were comparable for the two approaches, major complications occurred only with the fluoroscopically guided technique.[20] US-guided PBD tended to be more successful from the left side, fluoroscopically guided PBD from the right.

For more information on the complications of PTC, see Percutaneous Transhepatic Cholangiography.