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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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500
What is the Bismuth-
Corlette classification?
It is a classification system used in
patients with hilar cholangiocarcinoma
to describe the anatomic location of high
bile ducts obstructions.
What surgical
procedure is most
commonly associated
with biliary leaks?
Laparoscopic cholecystectomy.
When seen on imaging,
what is the significance
of atrophy of affected
liver segments?
Parenchymal atrophy is caused by
chronic biliary or portal venous
obstruction. Drainage of these segments
is less likely to provide a benefit to
recovered liver function.
What are the
findings suggestive of
choledocholithiasis on
transabdominal US?
A dilated CBD >6mm is the generally
accepted cutoff used to classify the duct
as dilated.
The CBD diameter, however, increases
with age, so older adults may have a duct
>6mm in the absence of disease.
Other signs of hepatobiliary stone
disease include gallbladder wall
thickening, cholelithiasis, and
pneumobilia.
What is Mirizzi
syndrome and how
does it present?
It is defined as the obstruction of the
common hepatic duct secondary to
extrinsic compression from a stone
located within the cystic duct or
Hartmann’s pouch of the gallbladder. It
also presents with jaundice, fever, and
right upper quadrant pain; however,
particular attention must be directed
toward the detection of potential
cholecystobiliary fistulas.
J. J. Bundy et al.
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Indications/Contraindications
What are PTC and
PTBD?
PTC is a minimally invasive diagnostic
procedure that involves the placement
of a small-gauge needle into peripheral
biliary tract under image guidance,
followed by the injection of contrast
to delineate biliary anatomy and
detect biliary obstructions. Following
cholangiography, a tube or stent may be
placed for external or internal drainage
(PTBD).
What is PC? Cholecystostomy is a therapeutic
procedure that involves the image-
guided placement of a tube for external
drainage of gallbladder contents.
What are the
indications for
percutaneous biliary
interventions according
to the Society of
Interventional
Radiology (2010)
guidelines?
PTC: Define the level of obstruction
in patients with dilated bile ducts,
evaluate for bile duct stones, determine
the etiology of cholangitis, evaluate and
determine the site of bile duct leak, and
determine the etiology of transplanted
hepatic graft dysfunction.
PTBD: Provide biliary drainage,
decompress obstructed biliary tree,
divert bile and place stents in bile
duct defects, provide portal of access
to dilate biliary strictures, remove bile
duct stones, stent malignant lesions,
brachytherapy, endoluminal tissue
sample, and foreign body retrieval.
PC: Gallbladder access, management
of cholecystitis, portal for removal of
stones, biliary tract access, decompress
obstructed biliary tract, divert bile from
bile duct defect, and provide portal of
access for the therapeutic processes
listed under PTBD.
(continued)
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What are the
contraindications to
percutaneous biliary
interventions?
The primary absolute contraindication
to these interventions is uncorrectable
coagulopathy. The Society of
Interventional Radiology generally
recommends correcting the INR
to ≤1.5 and transfusing platelets
to a level of ≥50,000/μL.Relative
contraindications include attempting
access into non-dilated ductal system or
a non-distended gallbladder, allergy to
iodinated contrast agents, and ascites.
When should the
placement of internal
biliary stents be
avoided?
Stent placement should not be
performed when there is infected bile
or active hemobilia.
Relevant Anatomy
What is the route of
biliary drainage?
The confluence of the right and left
hepatic ducts (the primary biliary
confluence) forms the common
hepatic duct. The common hepatic
duct joins the cystic duct to form
the common bile duct. The common
bile duct joins the pancreatic duct
close to the ampulla of Vater, which
drains into the descending part of the
duodenum.
According to the
Couinaud classification
of liver segments, which
segments compose the
left hepatic lobe? Right
hepatic lobe?
The left lobe is composed of by
segment 1 (caudate lobe), segment 2
(superior and posterior), segment 3
(anterior and inferior), and segment 4.
The right hepatic lobe is divided into
the anterior (segments 5 and 8) and
posterior (segments 6 and 7) sectors
by the right hepatic vein.
J. J. Bundy et al.
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What is the ideal location
for initial biliary tree
catheter cannulation?
Third-order or higher bile ducts
are preferable for initial catheter
placement so as to avoid injury to
larger central vascular structures and
to ensure adequate working room
proximal to the site of duct injury or
occlusion.
Where are the ducts of
Luschka located and
what is their importance?
The ducts of Luschka (subvesicular
ducts) are small, accessory biliary
ducts 1–2mm in diameter that
originate in the right hepatic lobe and
course along the center or periphery
of the gallbladder fossa. Following
the cystic duct, the ducts of Luschka
are the most common cause of post-
cholecystectomy bile leaks.
Where does
cholangiocarcinoma most
commonly develop?
Within the extrahepatic bile
ducts. When the tumor involves
the hepatic bifurcation (hilar
cholangiocarcinoma), it is called a
Klatskin tumor.
What are the
classifications of
obstructions used in
Bismuth-Corlette system?
Type I: Tumors below the confluence
of the left and right hepatic ducts.
Type II: Tumors reach the confluence,
but do not involve the right and left
hepatic ducts.
Type III: Tumors occluding the
common hepatic ducts and either the
right (IIIa) or left (IIIb) hepatic duct.
Type IV: Tumors that are metacentric
or involve the confluence and both
the right and left hepatic duct.
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Relevant Materials
Is antibiotic prophylaxis
recommended
by the Society of
Interventional
Radiology (2010) prior
to biliary interventions?
Antibiotic prophylaxis is recommended;
however, no consensus has been
reached on the first-line agent.
Common antibiotics choices include:
ceftriaxone, ampicillin/sulbactam,
cefotetan plus mezlocillin, and
vancomycin or clindamycin plus
aminoglycoside if penicillin-allergic.
What is an internal-
external biliary drain?
It is a drainage catheter with a locking
loop located in the duodenum and
multiple side holes. This form of drain
allows for either external drainage to
a bag or the exteriorized portion of
the catheter may be capped to force
internal drainage of bile.
When would an
external biliary drain be
placed?
This form of drain may be placed
when the biliary obstruction cannot be
crossed or in septic patients in whom
minimal manipulation is desired.
When would stents be
placed within the biliary
system?
Biliary stents are generally placed for
malignant biliary obstruction when
duct patency may be compromised for
a prolonged period. Once stent patency
is confirmed, drains may be removed
leaving the patient without external
devices and improved quality of life.
General Step by Step
What is the
common anatomic
landmark to select
for right-sided
biliary drainage?
A low intercostal approach near the
mid-axillary line is preferred to avoid
transgression of the lung pleura. Generally,
if the needle enters at or below the
superior margin of the 11th rib, this
complication may be avoided.
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What is the
common approach
for access of the left
biliary system?
Sub-xiphoid US-guided puncture using a
21-gauge needle or fluoroscopic-guidance
with the needle directed toward the
liver and 30–45 degrees posteriorly and
superiorly.
What signs indicate
the puncture of the
biliary system?
As the needle is slowly withdrawn, contrast
is injected into the liver parenchyma. When
contrast is injected into the hepatic arteries,
a pulsatile flow directed toward the liver
periphery is observed. Hepatic veins and
the portal venous system are non-pulsatile
with flow into right-angled tributaries. Bile
ducts are recognized by slow flow directed
centrally.
After gaining access
into the biliary
system, how is
the biliary system
decompressed?
A 0.018-inch guidewire is inserted into the
needle within the biliary system and then a
coaxial transition set is advanced over the
guidewire. This will consist of a 5- or 6-F
sheath, which will allow bile to flow out of
the sheath sidearm. This bile may then be
sent for culture.
How are drainage
catheters placed
within the biliary
system?
Once obstructions have been crossed
using a 0.035-inch straight, floppy tip wire
and the wire has been passed into the
duodenum, the original wire is exchanged
for a 0.035-inch exchange guidewire. Over
this wire, the tract may be sequentially
dilated to allow placement of an 8- to 12-F
drainage catheter.
How are ductal
strictures dilated?
High-pressure balloons, which are
oversized by approximately 20% of the
estimated duct diameter, are used to dilate
ductal strictures.
(continued)
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What are the
general steps
involved with PC?
Under US guidance, the gallbladder is
accessed with a needle and placement
within the gallbladder is confirmed with
fluoroscopic contrast-injection. A guidewire
is then advanced through the needle and
coiled within the gallbladder. Following the
dilation of the tract, an 8-to-10-F locking
pigtail catheter is then advanced and
formed within the gallbladder to allow for
decompression.
Complications
What are the most
common complications
following PTC?
Sepsis, bile leak, hemorrhage, and
pneumothorax occur at a rate of 2%
overall.
What is the most
common cause of sepsis
during PTC?
Sepsis generally results from over-
injection of contrast into infected biliary
ducts.
What are the most
common complications
following PTBD?
Major complications following
PTBD occur in 8% of cases with
sepsis and hemorrhage as the leading
complications. Other complications
include abscess formation, pleural
transgression, colonic perforation, bile
leak, and death.
What is the leading
cause of major
hemorrhage following
biliary interventions
and how is it managed?
Injury to the hepatic artery by a needle
or catheter may lead to extravasation
or pseudoaneurysm formation.
Bleeding which does not subside within
24–48hours generally requires an
arteriogram followed by intervention
with embolics.
What complications are
associated with PC?
Bile leak with associated peritonitis,
bleeding, sepsis, and catheter
dislodgement are documented to occur
in 5% of cases.
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What is the ideal tract
placement for PC to
avoid dislodgement?
Tract placement through the liver and
bare area has been suggested as a more
stable tract that minimizes the impact of
respiratory movement.
Landmark Research
Hepatic arterial injuries after percutaneous biliary interven-
tions in the era of laparoscopic surgery and liver transplanta-
tion: experience with 930 patients.
Fidelman N, Bloom AI, Kerlan RK, LaBerge JM, Wilson
MW, Ring EJ, et al. Hepatic Arterial Injuries after
Percutaneous Biliary Interventions in the Era of Laparoscopic
Surgery and Liver Transplantation: Experience with 930
Patients. Radiology. 2008 Jun 1;247(3):880–6.
• Retrospective review of 930 patients undergoing percuta-
neous biliary interventions to assess for factors associated
with arterial injuries.
• The overall rate of arterial injury in the study population
was 2.2% with no significant difference in the rate of arte-
rial injury among patients with malignant biliary obstruc-
tion, those with a history of bile duct injury, and those with
complications of liver transplantation.
• A 3.7-fold higher rate of AI was observed after PTBD than
after PTC.
Society of Interventional Radiology Quality Improvement
Guidelines for Percutaneous Transhepatic Cholangiography,
Biliary Drainage, and Percutaneous Cholecystostomy
Saad WEA, Wallace MJ, Wojak JC, Kundu S, Cardella
JF. Quality Improvement Guidelines for Percutaneous
Transhepatic Cholangiography, Biliary Drainage, and
Percutaneous Cholecystostomy. Journal of Vascular and
Interventional Radiology. 2010 Jun 1;21(6):789–95.
• Outlines the definitions, indications, and complications for
three commonly performed biliary interventions
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• Provides procedure-related complication thresholds which
should require a review to be performed to determine
causes and to implement changes if the rates exceed the
thresholds
Comparison of percutaneous transhepatic biliary drainage
and endoscopic biliary drainage in the management of malig-
nant biliary tract obstruction: a meta-analysis.
Zhao X, Dong J, Jiang K, Huang X, Zhang W.Comparison
of percutaneous transhepatic biliary drainage and endoscopic
biliary drainage in the management of malignant biliary tract
obstruction: a meta-analysis. Dig Endosc. 2015
Jan;27(1):137–45.
• Meta-analysis of eight trials including 692 patients the with
management of malignant biliary tract obstruction.
• This study revealed no significant difference in therapeutic
success between PTBD and endoscopic biliary drainage.
• After excluding two studies that appeared to be outliers,
PTBD exhibited a better therapeutic success rate and a
lower incidence of cholangitis than endoscopic biliary
drainage.
Comparing percutaneous primary and secondary biliary
stenting for malignant biliary obstruction: A retrospective
clinical analysis.
Chatzis N, Pfiffner R, Glenck M, Stolzmann P, Pfammatter
T, Sharma P.Comparing percutaneous primary and second-
ary biliary stenting for malignant biliary obstruction: A retro-
spective clinical analysis. Indian J Radiol Imaging.
2013;23(1):38–45.
• Retrospective review of 62 patients undergoing percutane-
ous biliary stenting for obstructive jaundice.
• Secondary biliary stenting (staged procedure) patients had
a higher rate of complications in general as well as a higher
rate of severe complications than patients who underwent
primary biliary stenting.
• By virtue of requiring shorter hospital stays, primary stent-
ing is likely to be more cost-effective.
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Percutaneous cholecystostomy: long-term outcomes in 324
patients.
Bundy J, Srinivasa RN, Gemmete JJ, Shields JJ, Chick
JFB. Percutaneous Cholecystostomy: Long-Term Outcomes
in 324 Patients. Cardiovasc Intervent Radiol. 2018
Jun;41(6):928–34.
• Retrospective review of 324 patients undergoing cholecys-
tostomy tube placement.
• Technical success rate of tube placement was 100% with
no major complications.
• Mean cholecystostomy tube indwelling time was 89days;
however, there are a small proportion of patients (4%)
that are continually undergoing cholecystostomy tube
changes with no future plans for definitive treatment.
Common Questions
What is the ideal location
of the drainage catheters
to allow for appropriate
decompression of the
biliary system?
Catheters should be positioned
to allow the sideholes to be both
proximal and distal to the leak or
obstruction.
How often should biliary
drains be flushed?
Drains draining bloody bile should
be flushed with 5–10mL of normal
saline every 6 to 8hours. Once
normal appearing bile is draining,
flushing can be performed once
daily.
How long does it take for a
tract to mature?
Tracts must mature for
approximately 3weeks before the
catheter may be removed; however,
it may take up to 6weeks if a trans-
peritoneal approach was used.
(continued)
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