Bile duct interventions

Percutaneous transhepatic cholangiography (PTC) and drainage procedures

The transhepatic approach for diagnostic visualization of the bile ducts was originally described by Burkhardt and Müller in 1921 with injection of contrast media into the gallbladder through a needle introduced through the liver. This technique was modified in 1937 by Huard et al. who injected Lipiodol directly into the bile ducts. It was only after Carter and Leger reported their experiences using water-soluble contrast material that this technique became more widely used. The method was  further improved and popularised by Okuda et al. in 1974 by using a thin flexible needle of 0.7 mm outer diameter. This fine-needle eliminated the need for immediate operation following the procedure.

The main indication for PTC is obstructive jaundice which is primarily diagnosed by ultrasound and CT. Although these two latter methods are sensitive methods of distinguishing obstructive from non-obstructive jaundice, demonstration of small lesions or partial obstructions and biliary tree anatomy is beyond their capabilities. In addition, 10 to 20% of patients with obstructing lesions such as common duct stones, strictures and tumors will not have dilated ducts demonstrable by ultrasound or CT. In these cases cholangiography by percutaneous or endoscopic routes is invaluable. For diagnostic purposes PTC has partly been replaced by endoscopic retrograde cholangiography (ERC). However, if ERC fails or in patients who are candidates for biliary drainage, especially with high obstructions, PTC is still the first step for opacifying the bile ducts and demonstrating the exact site of obstruction be it by tumor, stones or inflammation. Further indications are bile leakages after surgery or trauma which may also be treated with catheter drainage. In 1966, Seldinger reported his experience with transhepatic cholangiography by a right intercostal approach using a sheathed needle which allowed external drainage of the biliary system following cholangiography. The technique was further developed and refined using specialised guidewires and catheters which allow complete obstructions to be crossed and combined internal/external drains with antegrade flow through the catheter into the duodenum to be deployed.

The main indication for percutaneous biliary decompression and drainage is the non-surgical palliation of malignant biliary obstruction. Whenever possible, definitive drainage should be established by internal drainage with an endoprosthesis. Because of the significantly lower mortality rate the traditional treatment of surgical biliary-enteric anastomoses should be replaced by percutaneous or retrograde endoscopic placement of an endoprosthesis. Instead of conventional 8 to l4F plastic stents expandable metal prostheses of 10 mm diameter are increasingly used for palliation of malignant jaundice (Fig. 11). For obstruction of the common bile duct these prostheses can often be placed endoscopically (Fig. 12). For bilar lesions or lesions requiring drainage of multiple ducts a percutaneous approach from a right lateral and/or anterior epigastric approach is preferred. Using these methods internal

drainage is possible in over 90% with long-term primary patency ranging from 75-80%.

Percutaneous biliary drainage and balloon dilation of benign biliary duct strictures, surgical anastomoses or sclerosing cholangitis are an important alternative in these often very difficult situations which have limited surgical options apart from liver transplantation. Long-term drainage with plastic tubes is often required particularly for intrahepatic strictures. Expandable metallic prostheses should only be used for extrahepatic lesions or anastomotic strictures, but only as a last resort if multiple balloon dilations have failed. Percutaneous interventions for biliary calculi have been rendered much less common with the advanced techniques of retrograde endoscopic papillotomy and stone retrieval.

Christoph Zollikofer