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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3657_Библиотеки_им_академика_М_И_Перельмана.pdf
40 Biliary Drainage
445
Fig. 40.4 Malignant biliary obstruction treated by percutaneous drain-
age. A middle-aged man with metastatic colon cancer presented with
jaundice and itching. His biliary obstruction was alleviated by percutaneous transhepatic biliary drainage (PTBD). (a) A PTC was performed
Key Point
Catheter sideholes should be proximal and distal to the
leak/obstruction to allow appropriate drainage of bile.
Key Point
Lock a pigtail catheter by pulling back on the suture
that exits the catheter near the catheter hub.
As with any invasive procedure, percutaneous biliary
drainage can be associated with complications. The major
complications of percutaneous transhepatic cholangiography
and biliary drainage are bleeding, infection, and damage to
surrounding structures.
Key Point
Complications of PTC and PTBD:
• Hemobilia
• Hemoperitoneum
• Hemothorax
• Pseudoaneurysm formation
• Infection/sepsis
• Pleural transgression
• Colonic perforation
• Gastric perforation
showing obstruction of the common hepatic duct near the conuence of
the right and left bile ducts. (b) Internal-external biliary drainage catheters were inserted thru the right and left ducts across the obstruction
into the duodenum
Bleeding is usually secondary to an injury of a hepatic
artery by the needle or catheter leading to frank extravasation
or pseudoaneurysm formation. The bleeding may be manifest
by hemobilia, hemoperitoneum, or hemothorax. Bleeding is
clinically manifested by tachycardia, hypotension, abdominal
pain, chest pain, and shortness of breath. Hemobilia may masquerade as gastrointestinal bleeding with melena or less often
hematemesis. GI bleeding within 24–48 h following biliary
drainage is usually secondary to hemobilia. Immediate resuscitative measures are required with replenishment of volume
either with crystalloid or, more appropriately, transfusion of
packed red blood cells. Transfer to a higher level of care and
emergent angiography are usually warranted, as most bleeding
following biliary drainage can often be managed with transcatheter embolization. On rare occasions, embolization or surgical intervention is required, particularly if the damaged
vessel is an intercostal artery or diaphragmatic arterial branch.
Bleeding from a portal vein (or less commonly, hepatic vein)
transgression can usually be managed with catheter repositioning, catheter upsizing and supportive care. Rarely, embolization via percutaneous access may be required for major
portal vein bleeding.
Sepsis following percutaneous biliary drainage can be
severe and is usually encountered when the biliary system is
colonized or frankly infected at the time of drainage. All
patients undergoing percutaneous biliary drainage should
receive prophylactic antibiotics with coverage for gramnegative organisms as well as enterococcus. Over-injection of
contrast media leading to distension of the obstructed biliary
446
Fig. 40.5 Malignant biliary
obstruction treated by
placement of an indwelling
metallic stent.
Cholangiography shows a
long-segment narrowing of
the common hepatic duct. A
self-expanding metallic stent
was inserted across the
obstructing lesion with
marked improvement in bile
duct drainage
R. K. Kerlan Jr. and J. LaBerge
system and reux of infected bile into the system circulation
should be avoided as this is a common precipitating factor of
severe sepsis. The presence of biliary calculi, particularly
obstructing stones, is frequently associated with sepsis following biliary drainage due to the higher incidence of infected
bile. Management includes uid resuscitation, antibiotics,
and pressors as well as transfer to an intensive care environment. If no infectious complications are encountered, it is
unnecessary to treat patients with antibiotics following the
procedure.
Damage to adjacent organs including pleural transgression (with possible bilothorax), colonic perforation, or gastric perforation is occasionally encountered. Bilothorax may
necessitate the placement of a thoracostomy tube; this
requires placement of a new PTBD if leakage persists.
Violation of the colon may require surgical intervention and
repair. Gastric transgression generally requires no specic
remedy, and transgastric biliary drainage may be performed
intentionally in certain anatomic situations.
Imaging following the placement of a percutaneous biliary
drain other than the intra-procedural cholangiogram is not
usually warranted. Procedures complicated by hemorrhage
require cross-sectional imaging which may indicate the location and source of bleeding. In this circumstance, computed
tomographic angiography with delayed scans should be performed to assess for the presence of extravasation.
Follow-up catheter cholangiography with routine catheter
maintenance is institutionally dependent; however it is usually performed 2–3weeks following initial biliary drainage
and at 6- to 8-week intervals if chronic internal or internalexternal biliary drainage is warranted. In many circumstances,
it may be decided to proceed with metallic stent placement in
conjunction with or soon after percutaneous biliary drainage
(Fig.40.5). Patients who are being managed for obstructing
calculi should return within 2weeks for percutaneous removal
of calculi or facilitation of endoscopic sphincterotomy and
stone removal.
Conclusion
Interventional radiologic imaging and intervention play an
important role in the diagnosis and management of biliary
disease. Cross-sectional imaging with ultrasound, MR, and
CT is used to identify the type of biliary pathology and location of biliary obstruction or leak. PTBD can be performed to
heal a stulous leak, relieve obstruction, and palliate malignant biliary disease. Furthermore, PTBD may be used in secondary interventions such as for stone extraction, stenting of
malignant obstructions (see Fig.40.5), and balloon dilatation
of benign strictures.
References
1. Barrett KE. Ganong’s review of medical physiology. 24th
ed. New York: McGraw-Hill Medical; 2012. p. 512. ISBN
978-0-07-178003-2
2. Miura S, Kanno A, Masamune A, Hamada S, Takikawa T, Nakano
E, etal. Bismuth classication is associated with the requirement
for multiple biliary drainage in preoperative patients with malignant perihilar biliary stricture. Surg Endosc. 2015;29(7):1862–70.
3. McCune WS. ERCP--the rst twenty years. Gastrointest Endosc.
1988;34(3):277–8.
40 Biliary Drainage
447
4. Ring EJ, Husted JW, Oleaga JA, Freiman DBA.Multihole catheter
for maintaining longterm percutaneous antegrade biliary drainage.
Radiology. 1979;132(3):752–4.
5. Oleaga JA, Ring EJ. Interventional biliary radiology. Semin
Roentgenol. 1981;16(2):116–24.
6. Harbin WP, Ferrucci JT Jr. Nonoperative management of malignant
biliary obstruction: a radiologic alternative. AJR Am JRoentgenol.
1980;135(1):103–7.
7. Okuda K, Tanikawa K, Emura T, Kuratomi S, Jinnouchi S.
Nonsurgical, percutaneous transhepatic cholangiography--diagnostic signicance in medical problems of the liver. Am J Dig Dis.
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8. Sharaiha RZ, Khan MA, Kamal F, Tyberg A, Tombazzi CR, Ali B,
etal. Efcacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic
review and meta-analysis. Gastrointest Endosc. 2017;85:904–14.
9. Zhang GY, Li WT, Peng WJ, Li GD, He XH, Clinical XLC.
Outcomes and prediction of survival following percutaneous
biliary drainage for malignant obstructive jaundice. Oncol Lett.
2014;7(4):1185–90.
10. Levy JL, Sudheendra D, Dagli M, Mondschein JI, Stavropoulos
SW, Shlansky-Goldberg RD, et al. Percutaneous biliary drainage
effectively lowers serum bilirubin to permit chemotherapy treatment. Abdom Radiol (NY). 2016;41(2):317–23.
11. Stamp U, Hackert T, Radeleff B, Sommer CM, Stamp S, Werner
J, et al. Percutaneous management of postoperative bile leaks
after upper gastrointestinal surgery. Cardiovasc Intervent Radiol.
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12. Fang Y, Gurusamy KS, Wang Q, Davidson BR, Lin H, Xie X, etal.
Meta-analysis of randomized clinical trials on safety and efcacy of
biliary drainage before surgery for obstructive jaundice. Br JSurg.
2013;100(12):1589–96.
Part XI
Biopsies, Drainage, and Enteric Access
Biopsy Techniques
SolomonAbay andAdamB.Winick
Introduction
Nearly every patient is touched by a biopsy during their
lifetime. Few cancer diagnoses are made without a biopsy,
with increasingly larger samples required for an array of
genetic testing. An infection not resolving with antibiotics
will undergo sampling to cater treatment choice. With a
non- focal biopsy, diagnosis of underlying hepatic or renal
disease can aid in medical management and risk stratication. The interventionalist can play a crucial role in patient
care by understanding when a biopsy is appropriate as well
as the safest route and best modality to access the target
organ or lesion. Differentiation between malignant and
benign with further categorization between benign tumor,
infectious, inammatory, and sterile is critical for dening
the algorithm a patient will follow for appropriate
treatment.
Prior to percutaneous technological advances, open surgical biopsy was the method used to obtain tissue samples.
The earliest known writings of what can be described as percutaneous needle aspiration date back to the tenth-century
AD medical text by Albucasis titled “The Method of
Medicine” [1, 2]. In more modern times, ne needle aspiration (FNA) is traced back to the German physician Kun, who
described using “an exploring needle incorporating a depression at the tip with cutting edges for extracting tissue from a
subcutaneous tumor” in the late 1840s [3, 4].
Percutaneous image-guided biopsy is the standard of
care for tissue sampling in the least traumatic fashion with
the highest success rate and lowest risk. Prior to the current
era in medicine, biopsies were usually performed blindly
41
by utilizing palpation, anatomical structures, and usual
locations of organs to be biopsied. Deep structures frequently required an open surgical approach to obtain a tissue sample. Percutaneous methods have supplanted the
need for open biopsy in most cases; however surgery
remains the last option for hard to reach lesions and for
brain lesions.
Clinical Indication
Each patient scenario must be assessed individually prior to
performing a biopsy. The risks and benets of the procedure
must be weighed on a case-by-case basis depending on
each patient’s clinical picture as well as the urgency of the
situation.
There are three main situations in which a biopsy is performed: organ (non-focal) sampling, tissue (focal) sampling,
and uid sampling. Non-focal organ sampling is typically
performed to determine an underlying cause of organ dysfunction such as a renal biopsy to determine the source of
renal failure (Fig.41.1). In the case of a liver biopsy, this can
aid in understanding the severity of cirrhosis and degree of
iron deposition in hemochromatosis or identify the unknown
cause of liver dysfunction (Fig.41.2). Furthermore, repeat
biopsy can determine treatment response and determine if
further treatment is warranted.
Key Point
The three main types of biopsies:
S. Abay · A. B. Winick (*)
University of Virginia Health System, Department of Radiology
and Medical Imaging, Charlottesville, VA, USA
e-mail: sta3b@virginia.edu; awinick@virginia.edu
© Springer International Publishing AG, part of Springer Nature 2018
N. A. Keefe et al. (eds.), IR Playbook, https://doi.org/10.1007/978-3-319-71300-7_41
• Organ (non-focal) sampling
• Tissue (focal) sampling
• Fluid sampling
451
452
S. Abay and A. B. Winick
Fig. 41.1 (a) US-guided non-focal renal biopsy with needle guide. A
78-year-old male with a past history of multiple myeloma presents with
acute kidney injury and nephrotic syndrome. Ultrasound shows a normalappearing kidney (arrow). The decision was made to obtain a non-focal
Fig. 41.2 US-guided non-focal liver biopsy with needle guide. A
31-year-old male with persistently elevated liver function tests of
unknown etiology. Biopsy needle (arrow) is seen following the path of
the needle guide (dotted line). Pathology showed chronic portal inammation and sinusoidal dilation without evidence of cirrhosis
Focal tissue sampling is frequently performed for diagnostic purposes and in order to guide oncologic treatment
options (Fig. 41.3). Multiple large core biopsies are often
required for genomic testing. Additionally, sampling can
determine if a focus is infectious or sterile in order to guide
proper antibiotic selection. Fluid sampling, such as a pleural
effusion or ascites, can determine if the etiology is malignant
versus benign and infectious versus sterile (refer to Chap. 42
for more information).
renal biopsy to determine the underlying etiology. (b) Biopsy needle is
now seen within the kidney parenchyma (big arrow), following the path
of the needle guide (dotted line). Pathological diagnosis was AL-type
amyloidosis, severe tubular atrophy, and severe interstitial brosis
The only true absolute contraindication to performing a
biopsy is uncorrectable coagulopathy. Relative contraindications include difculty identifying a safe route to reach the
area of interest and body habitus. This becomes important if
the patient is too large to t into the bore of the CT and allow
safe access of the needle. Additionally, an ultrasound beam
may not penetrate deep enough to adequately visualize a target. As with all interventional procedures, appropriate sedation must be administered ranging from local anesthesia to
general anesthesia depending on the invasiveness of the
biopsy and patient’s ability to tolerate the procedure.
Interventional Therapy
Modality ofChoice
Scientic advancements in uoroscopy, ultrasound, and CT
have enabled these technologies to be utilized in biopsy
techniques (Table 41.1). The prevalence and availability of
these modalities within radiology departments has led to a
marked improvement in the accuracy and safety of the biopsy
procedure [5–7]. It should be noted that MRI-guided biopsies
are also possible. However, access is limited in many centers,
and MRI guidance has not been shown to be advantageous
over other modalities except in specic circumstances such
as in breast pathology. Prior to performing a procedure, each
patient’s situation must be reviewed in order to perform the
best procedure for each patient. Location of the target biopsy
as well as the likely biopsy path should be reviewed for
41 Biopsy Techniques
453
Fig. 41.3 (a) CT-guided bone biopsy. A 40-year-old female with no
signicant past medical history who presented with acute right hip pain
and was found to have a lytic lesion in the right femoral neck on CT,
safety as well as to determine imaging modality. Radiation
exposure should be taken into account, particularly for
pediatric patients.
Key Point
For pediatric patients, radiation exposure should be limited whenever possible. Consider US biopsy if feasible.
Biopsy approach decisions are based on institutional
preference and the experience of the physician. Ultrasound,
if possible, is nearly always the rst choice due to the lack of
Table 41.1 Comparison of different modalities for imaging guidance [8]
Modality Advantages Disadvantages
Fluoroscopy Availability
Inexpensive
Ultrasound Real time
Availability
Portable
No radiation
Inexpensive
Excellent visualization
of supercial structures
CT Excellent visualization
of supercial and deep
structures, as well as
osseous lesions
(Fig.41.3)
Target lesion may only be
visualized on crosssectional imaging
Interposed structures not
visible
Radiation exposure
Requires a good acoustic
window for biopsy (can
be obscured by bowel
gas, bone, deep location)
Radiation exposure
Off-plane angulation
difcult with CT gantry
Expensive
Can require contrast
administration
with an associated pathological fracture (arrow). (b) CT-guided bone
biopsy (arrow) can be seen within the lytic lesion. Pathological diagnosis
was high-grade sarcomatoid neoplasm
radiation and availability. Ultrasound is exceptional at
depicting vascular structures which could impede reaching a
target and allow the physician to determine an accurate pathway to decrease the risk of a bleeding complication
(Fig.41.4). Furthermore, it allows the physician to visualize
complex pathways to reach the target due to its ability to
allow imaging in any plane in real time.
CT and MRI are planar modalities– they create an image
and do not lend themselves easily to complex angulation
Fig. 41.4 US-guided FNA of left thyroid nodule. A 55-year-old female
with squamous cell carcinoma of the right buccal mucosa who was
found to have a left thyroid nodule on routine follow-up neck CT.Image
shows the nodule (small arrow) with the biopsy needle inside (large
arrow). Doppler US (not shown) was used to conrm the location of the
carotid artery (star) and internal jugular vein (outside of the eld of
view laterally). Pathological diagnosis was benign follicular epithelium
and colloid
454
S. Abay and A. B. Winick
Fig. 41.5 (a) CT-guided lung mass biopsy. A 69-year-old male with a
history of multiple myeloma status post-autologous stem cell transplant, invasive aspergillosis, and COPD.CT of the chest showed a subpleural mass-like consolidation in the left upper lobe measuring 18 ×
16mm (arrow). Note the left lower lobe consolidation (arrowhead) consistent with aspergillosis. (b) Biopsy of the right lung mass (small
paths to reach the target. The operator must conceptualize the
pathway to reach the target. One advantage of CT guidance is
allowing visualization of the needle in its entirety along
the path chosen to ensure safety in reaching the target and
avoiding critical structures (Fig.41.5). On occasion, it may
be necessary for the biopsy device to go off plane in order to
avoid vital structures on the path to the target area.
MRI has been used for biopsies; however, access to the
patient and “real-time” monitoring of needle position and
movement are difcult. MRI procedures also require the use
of MRI compatible equipment. Many institutions have abandoned MRI for routine procedures due to availability, cost,
and constraints of use. “Interventional” open bore-type mag-
arrow) was performed. The biopsy needle (large arrow) can be seen
advanced toward the mass. (c) The entirety of the needle is visualized as
it enters the mass, allowing for avoidance of critical structures.
Pathological diagnosis was acute on chronic inammatory changes
consistent with organizing PNA
nets which might allow better access to the patient have been
shown to lack protability in the long run. Currently, breast
lesions are the most frequently biopsied lesions via MRI
guidance when they are not easily visualized on mammogram or ultrasound.
Location toObtain Biopsy
Biopsy tissue yield can vary depending on where the biopsy
sample is taken. Tumors typically grow outward from a central
focus of cells in a concentric spherical pattern. As they
enlarge, the central aspect can become necrotic due to loss of
Poor location
peripheral aspects
41 Biopsy Techniques
455
Good location
Fig. 41.6 Proper tissue sampling location within a lesion
Neovascularity
supplying the
of the tumor
Necrotic center
Fig. 41.7 (a) US-guided focal renal biopsy (with needle guide). A
70-year-old male who presented with gross hematuria. CT of the abdomen/pelvis and US. demonstrated right renal mass (small arrow).
adequate blood supply. The peripheral aspect of the lesion
recruits vessels in a process termed neovascularization,
which enables the growth of the lesion. Pathologic evaluation is contingent upon visualization of cellular architecture
and preservation of live cells. Thus, the highest yield biopsy
is typically in the periphery of the lesion to avoid the necrotic
center (Figs. 41.6 and 41.7). For lesions that are complex
including both solid and cystic components, a biopsy should
be taken of the solid component; aspiration can be performed
of the cystic component for cell cytology.
Key Point
Sample the solid portion of a complex lesion. Sample the
peripheral of a solid lesion to minimize necrotic tissue.
Biopsy needle (large arrow) has not yet entered the mass. (b) Biopsy
needle tip (arrow) is seen within the mass. Pathological diagnosis was
renal cell carcinoma with sarcomatoid features
Needle Selection
There are two primary types of biopsies which can be performed for tissue sampling: ne needle aspiration (FNA) and
core needle biopsy. FNA is minimally invasive and can occasionally be used without image guidance for palpable lesions.
It works through capillary action as the cells move into the
biopsy needle. A hollow 22 or 25G needle is inserted into the
target tissue and the inner stylet is removed. The sharpened
edge of the outer core of the needle is moved back and forth
multiple times within the lesion to draw cells into the needle
(Fig.41.8). Alternatively, a syringe can be placed on the back
of the needle and aspirated to aid in cellular acquisition. Due
to the relatively small size, FNA is considered a safe procedure with minimal to no risk of damage to surrounding structures (Fig.41.9).
456
Fig. 41.8 FNA needle
varieties
S. Abay and A. B. Winick
of this large sample is that it maintains the spatial cellular
arrangement of the lesion to aid in diagnosis. Larger samples,
particularly in the breast tissue which uses 9, 11, and 13G
needles, may be needed for genomic testing.
Depending on the particular scenario, one technique
may be advantageous in comparison to the other
(Table41.2). In certain circumstances, both FNA and core
biopsies may be obtained. For example, a small FNA biopsy
sample may be obtained for conrmation that the desired
lesion has been accessed prior to proceeding with the larger
core biopsy.
Fig. 41.9 FNA of lymph node. A 64-year-old female with a history of
lung cancer who was found on recent PET-CT to have a hypermetabolic
internal mammary lymph node concerning for metastasis. Ultrasound
demonstrates the biopsy needle (large arrow) within the lymph node
(thin arrow), which sits adjacent to the right margin of the sternum
(arrowhead), and immediately anterior to the right atrium of the heart
(star). Given this location, FNA was deemed a safer procedure than core
biopsy. Pathological diagnosis was benign, reactive lymph node
Key Point
FNA is easier to manipulate but yields small samples.
Core needle biopsy is more invasive but yields larger
samples, preserving tissue architecture.
A core biopsy uses a specialized needle in which the inner
needle component has a trough built into it that allows the tissue to fall into the cavity. An outer needle then passes secondarily over the rst component usually utilizing a spring
generated forward motion to shave off a piece of tissue into the
trough. This secondary outer needle also allows protection of
the fragment as the needle is withdrawn (Fig. 41.10). Core
needle biopsy is slightly more invasive than FNA as it requires
a larger gauge needle, typically 20 or 18G. The advantage
Biopsy Techniques
When performing a biopsy of an organ or target lesion, the
single stick or coaxial techniques can be employed. The single stick technique means that the entire biopsy device is
inserted and removed after each sample is taken. It is useful
when the lesion is readily available (e.g., supercial without
overlying structures and a direct, safe path to the lesion) and
when the bleeding risk is low. Either a core needle or FNA
biopsy can be performed using this technique.
The coaxial technique is useful in difcult to access areas
(e.g., deep tissue, overlying sensitive structures) or when there
is associated procedural risks (e.g., bleeding or pneumothorax) making multiple passes across the overlying tissue undesirable. The coaxial technique is performed by inserting a
needle with a hollow bore known as a coaxial or trocar needle
into the target tissue. This is left in place while a small gauge
needle is inserted through the coaxial needle to take multiple
samples. One signicant limitation of this technique that exists
when using ultrasound guidance is decreased conspicuity of
the target tissue due to potential introduction of air following
repeated insertions of the needle. This limitation can be minimized by dripping sterile saline into the coaxial needle hub
each time the smaller needle is withdrawn. When performing
a lung biopsy using the coaxial technique, the inner stylet of
the trocar needle should be replaced or the hub covered to
decrease the introduction of air through the needle, thus
decreasing the risk of a pneumothorax.