Biliary Tract Interventions

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Biliary tract interventions remain a tremendous technical challenge to the interventionalist and require appropriate clinical postprocedural management. The increased use of endoscopy for biliary tract evaluation and intervention has served to largely replace percutaneous techniques, resulting in a decreased number of patients requiring primary percutaneous transhepatic biliary interventions. However, those patients who do present for percutaneous biliary procedures often represent a more technically difficult subset. Thorough familiarity with normal and variant biliary tract anatomy, and experience with a variety of techniques, will allow for successful biliary tract interventions in complex situations. This article reviews the current role of percutaneous transhepatic interventions in the emergency evaluation and management of biliary tract disease.

Section snippets

Indications

Patients with biliary obstruction may present with a clinical scenario that dictates elective, urgent, or emergent intervention. Interventions may be divided into diagnostic and/or therapeutic procedures. Indications for percutaneous biliary interventions2 include the following:

  • Treatment of biliary obstruction in which endoscopy has failed or is not appropriate, for management of the following problems:

    • Obstructive jaundice

    • Infectious complications, such as sepsis and cholangitis

  • Evaluation and/or

Contraindications

Although no absolute contraindications exist for PTC and biliary drainage, there are several relative contraindications2 including the following:

  • Uncorrectable coagulopathy: patients taking both aspirin and clopidogrel have an increased risk of hemorrhagic complications. Correction of the coagulopathy to an international normalized ratio (INR) of 1.5 or less and platelet transfusion to at least 50,000 by administration of fresh frozen plasma is recommended. Platelet transfusion in patients

Preprocedural Imaging

Patients may present for PTC and biliary drainage because of either benign or malignant biliary obstruction. The initial noninvasive imaging evaluation of these patients is similar, regardless of the etiology of the obstruction, and typically consists of an ultrasound study, followed by either computed tomography (CT) (Fig. 1) or magnetic resonance imaging with or without magnetic resonance cholangiopancreatography. Preprocedural imaging studies will not only help to elucidate the etiology of

Postprocedural Management

Routine postsedation monitoring for 2-3 hours in a procedural recovery area is recommended following biliary drainage procedures. Most patients who require biliary drainage are moderately ill and will thus require hospital admission, with a subset that requires admission to the intensive care unit. All patients should be closely monitored for any evidence of sepsis and/or hemorrhage. Antibiotics should be continued until the results of the Gram stain and cultures are known, followed by

Complications

Infection and sepsis are the most common complications associated with biliary drainage procedures.5 The use of prophylactic periprocedural antibiotics can help to reduce the incidence of procedure-associated infections. Hepatic abscesses may occur following biliary interventions and typically present several weeks after the initial procedure. Patients who develop postprocedural abscesses may need catheter-directed drainage and a prolonged course of antibiotics. Although transient hemobilia

Cholecystostomy Tube Placement

Percutaneous cholecystostomy is an alternative treatment method in patients with acute cholecystitis who are at high risk for surgery due to comorbid diseases. The morbidity and mortality associated with emergent cholecystectomy are considerably higher in such patients: 55%-66% and 14%-30%, respectively.6 The morbidity and mortality rates of percutaneous cholecystostomy have been found to be much lower, less than 10% and 2%, respectively, and have resulted in successful treatment in 56%-100% of

Indications

Percutaneous cholecystostomy may be required in critically ill patients who have either calculous or acalculous cholecystitis and are either poor or nonoperative candidates. Acalculous cholecystitis is not limited to surgical or injured patients but has also been associated with diabetes, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, and shock or cardiac arrest. Children may be affected, particularly after a viral illness. There is a complex

Contraindications

A gallbladder that is completely packed with stones, so that it is unable to accommodate a drainage catheter securely, is a relative contraindication to percutaneous cholecystostomy, as is an uncorrectable coagulopathy.

Preprocedure Preparation

Patients requiring percutaneous cholecystostomy are generally very ill, with either sepsis or other concomitant disease processes. Those with acalculous cholecystitis are often in the intensive care unit and may have associated hemodynamic instability. The severity of the illness may preclude obtaining written informed consent from the patient, so that it may be necessary to obtain consent from the patient's health care proxy. The acceptable coagulation parameters and the increased risk of

Procedure

Given the severity of illness that is typically seen in these patients, this procedure can usually be performed at the bedside, if necessary, using ultrasound guidance. Rarely, CT guidance will be required for imaging guidance during percutaneous cholecystostomy.

A transhepatic route is preferred for cholecystostomy tube placement, as it is thought that this approach decreases the potential for intraperitoneal bile spillage, portal vessel injury, and colon injury but it carries a risk of

Postprocedural Management

As with other biliary procedures, the patient should undergo routine monitoring for signs of hemorrhage, worsening sepsis, or other clinical deterioration. Results of the Gram stain and culture may aid in determining the optimal antibiotic regimen. The catheter is placed to gravity drainage, coupled with periodic catheter flushing using 5 mL normal saline. If drainage output decreases, contrast may be injected under fluoroscopy via the cholecystostomy tube. A decreased output may be due to

Complications

Technical success rates for percutaneous cholecystostomy range from 95% to 100%.10, 11 Technical failures tend to occur in decompressed gallbladders, those with impacted stones and porcelain gallbladders, and where there is significant gallbladder wall thickening. The most common complication following percutaneous cholecystostomy is bile leakage.12 Theoretically, a transhepatic route should help to prevent bile leakage and painful bile peritonitis, although this has not been definitively

Conclusions

Percutaneous biliary tract interventions, although often technically difficult, represent a valuable diagnostic and therapeutic option for the management of often critically ill patients in whom endoscopic intervention has failed, or in whom surgery is a poor option. Proper patient assessment and preparation, appropriate preprocedural imaging, expertise with the technical aspects of the various interventions, and careful clinical management will help to insure optimal outcomes.

References (12)

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