Percutaneous biliary drainage: complications and efficiency at short and mean terms: about 50 cases

Transcription

1 Percutaneous biliary drainage: complications and efficiency at short and mean terms: about 50 cases Poster No.: C-1497 Congress: ECR 2016 Type: Scientific Exhibit Authors: M. Matri, L. Ben Farhat, I. Marzouk Moussa, W. Aloui, L Hendaoui ; Tunis/TN, Sidi Daoued/TN, La Marsa/TN Keywords: Biliary Tract / Gallbladder, Interventional non-vascular, Percutaneous, Cholangiography, Puncture, Complications, Obstruction / Occlusion, Neoplasia, Inflammation DOI: /ecr2016/C-1497 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Aims and objectives Percutaneous transhepatic biliary drainage (PTBD) is a common and an effective interventional radiology procedure for the primary or palliative treatment of many biliary abnormalities. Definition: PTBD is a therapeutic procedure that includes the sterile cannulation of a peripheral biliary radical after percutaneous puncture followed by imaging-guided wire and catheter manipulation. Placement of a tube or stent for external and/or internal drainage completes the procedure. Successful biliary drainage is defined as the placement of a tube or stent with use of imaging guidance to provide continuous drainage of bile. Indications: 1. Provide adequate biliary drainage. - Decompress obstructed biliary tree. - Divert bile from and place stent in bile duct defect 2. Provide a portal of access to the biliary tract for therapeutic purposes that include but are not limited to - Dilate biliary strictures - Remove bile duct stones - Stent malignant lesions - Brachytherapy/phototherapy - Endoluminal tissue sample or foreign body retrieval 3. Provide a portal of access to the biliary tract for mid- to long-term diagnostic purposes. Complications: The major complications are: 1- Intraprocedural: Sepsis, hemorrhage, inflammatory/infectious (abscess, peritonitis, cholecystitis, pancreatitis), Pleural, Death. 2- Postprocedural: Inadvertent catheter discontinuation requiring de novo percutaneous transhepatic cholangiography, death and/or surgery. The aim of this scientific poster is to: - Remind the indications of the biliary drainage and its terms. Page 2 of 17

3 - Evaluate the efficiency and early complications at short and mean term through a retrospective study of 50 cases. Methods and materials PTBD was performed in 50 patients: 24 men and 26 women, age range between 24 and 87 years (mean age = 61 years). A retrospective review of all cases was performed to evaluate technical success and complication rates over a period of two months. Before all procedures, coagulopathy were corrected and all patients received prophylactic intravenous broad-spectrum antibiotics. The procedures were all performed under local anesthesia. Bile duct puncture was performed under real-time scopic or ultrasound guidance. A guidewire was introduced under fluoroscopic control. Internal, internalexternal or external drainage was performed according to the indication and the state of the patient. Results Malignant tumors were the leading cause of malignant biliary obstruction (70% of cases) and Gallbladder cancer the most frequent diagnosis (57%). The etiologies of the 30% remaining benign biliary obstruction were dominated by post operative stenosis of the main bile duct. Fig. 1 on page 3 Fig. 2 on page 4 Fig. 3 on page 4 The technical success (hepatic ducts cannulated at the conclusion of procedure) was achieved in 98% of patients. Only in one case where the gallbladder tumor invaded the hilum with moderately dilated bile ducts, the biliary drainage was ineffective. Complications and adverse events occurred in 16 patients (32%), documented in patient's medical record immediately after the drainage to 3 weeks following the procedure. Immediately complications (till 24 hours) occurred in six patients (12%). The most common complication during drainage was hemobilia (6%). Immediately after the procedure hemobilia was observed in 3 patients. Two patients instantly during procedure had sepsis (4%). One patient (2%) suffered from acute cholangitis. Long-term complications of percutaneous biliary drainage appeared in 20% of cases (n=10). Of these 10 patients, 5 patients (10%) had bile leak, one patient (2 %) had drain dislocation, and 2 patients (4%) reported hepatic collection and wall abscess. Images for this section: Page 3 of 17

4 Fig. 1: Etiologies of biliary obstruction Fig. 2: Etiologies of malignant biliary obstruction Page 4 of 17

5 Fig. 3: Etiologies of benign biliary obstruction Page 5 of 17

6 Conclusion Discussion: A. Indications of percutaneous biliary drainage: Neoplastic bile obstructions PTBD is performed first when the obstacle is proximal: gallbladder tumors invading the hilum or cholangiocarcinoma. For distal tumoral obstruction such as tumor of the head of the pancreas or the lower bile duct cholangiocarcinoma, percutaneous treatment is envisaged after failure of endoscopic drainage or the surgical anastomosis. As a palliative treatment, biliary drainage improves patient's life quality by a disappearance of pruritus, a liver function recovery and by avoiding a surgical treatment. Non neoplastic bile obstruction PTBD is indicated after failure of surgery, sometimes in first-line in sclerosing cholangitis or post operative stenosis secondary to a wound of the main bile duct. B. Drainage technique: Puncture of the bile tract is usually performed on the right biliary tract by an intercostal way, rarely at the level of the epigastrium under ultrasound control especially in case of exclusion of the left biliary tract. In our study, the right intercostal approach was used in 82% of cases. After opacification of the biliary tract, a guide is introduced. Success rate of this procedure is close to 100% when the bile ducts are dilated. It ranges from 50 to 95% when the bile ducts are not dilated. In our series success rate was 98%. Different types of drainage: External drainage: The catheter is placed above the obstacle, to drain bile to the outside. This type of drainage is indicated when it comes to a context acute cholangitis. In this study, 62% of patients (n=31) has had external drainage: 32% was performed first and 23% after failure of internal or internal-external drainage. Internal-external drainage: The catheter is placed through the obstruction area. It allows communication between the biliary tract below the obstruction, biliary tract above and with the external environment. In our study, 6% of patients (n=3) has had internal-external biliary drainage, 4% after failure of internal drainage.fig. 6 on page 9 Fig. 7 on page 10Fig. 8 on page 12Fig. 9 on page 12Fig. 10 on page 13Fig. 11 on page 14 Internal drainage or Endoprothesis: A metal stent or a plastic prosthesis is placed at the level of the obstruction of which allows the flow of bile to the natural pathways. Endoprothesis was placed in 15 cases (30%). Fig. 12 on page 15 C. Complications Page 6 of 17

7 The literature reports that complications in less than 5% of cases and are most often minor. The major complications such as sepsis, hemorrhage, and localized infection or abscess formation are rare. Mortality as a result of this procedure is more often due to hemorrhage than sepsis. In our study, the most common postprocedure complication was hemobilia (6%), which also appeared in other series. However, because of the anatomy of portal triads, the procedure must be performed with suitable technique in order to prevent severe bleeding. Moreover, PTBD should not be performed on patients with nondilated bile ducts, because of high risk of complications. The success rate of PTBD for patients with dilated bile ducts is significantly greater. Despite prophylactic antibiotics coverage, sepsis can occur right after drainage or within few hours after the procedure. In our study, the number of sepsis reached 4%, although other studies show that these can be the most common complications after PTBD. Final conclusion: PTBD is an effective method of biliary tract decompression and it is an important alternative to endoscopic drainage. It can be performed with high technical success and low complication rates. Images for this section: Page 7 of 17

8 Fig. 4: External drainage: Puncture of the biliary tract by a needle and opacification of dilated biliary tract Page 8 of 17

9 Fig. 5: External drainage: Introduction of a metal guide prior to the establishment of the drain Page 9 of 17

10 Fig. 6: Internal-external drainage: Puncture and opacification of dilated biliary tract Page 10 of 17

11 Page 11 of 17

12 Fig. 7: External-inernal drainage: Gallstones upstream common hepatic duct obstruction Fig. 8: Internal-external drainage: Catheter placed through the obstruction area Page 12 of 17

13 Fig. 9: Internal-external drainage: Puncture and opacification of dilated biliary tract Page 13 of 17

14 Fig. 10: External-internal drainage Page 14 of 17

15 Fig. 11: Internal-external drainage: Catheter placed through the obstruction area Page 15 of 17

16 Fig. 12: Metal stent in the main bile duct Page 16 of 17

17 Personal information References 1. Knap D et al. Biliary duct obstruction treatment with aid of percutaneous transhepatic biliary drainage,alex J Med (2015). 2. Sut M, Kennedy R, McNamee J, et al. Long-term results ofpercutaneous transhepatic cholangiographic drainage for pallia-tion of malignant biliary obstruction.j. Palliat. Med.2010; 13: Kang MJ, Choi YS, Jang JY, et al. Catheter tract recurrence after percutaneous biliary drainage for hilar cholangiocarcinoma. World J. Surg. 2013; 37(7): Covey AM, Brown KT. Percutaneous transhepatic biliary drainage. Tech. Vasc. Interv. Radiol.2008; 11 (1): Smith TP, Ryan JM. Sepsis in the interventional radiology patient. J. Vasc. Interv. Radiol. 2004; 15: Yasunori M, Masatoshi K. Hepatocellular carcinoma with obstructive jaundice: endoscopic and percutaneous biliary drainage. Dig. Dis 2012; 30 (6):592-7 (13) 7. Saluja SS, Gulati M, Garg PK, et al. Endoscopic or percutaneous biliary drainage for gallbladder cancer: a randomized trial and quality of life assessment. Clin. Gastroenterol. Hepatol. 2008; 6: Van Delden OM, Lameris JS. Percutaneous drainage and stentingfor palliation of malignant bile duct obstruction. Eur. Radiol.2008; 18: Fedak Andrzej, Uchto Wojciech, Urbaniak Andrzej.Transcutaneal drainage intrahepatic biliary ducts as a method of paliative treatment of inoperative liver hilum tumours. Przeglad Lekarski 2013;70:5 10. Teixeira MC, Mak MP, Marques DF, et al. Percutaneous transhepatic biliary drainage in patients with advanced solid malignancies: prognostic factors and clinical outcomes. Gastrointest. Cancer 2013; 44: Dambrauskas Z, Paskauskas S, Lizdenis P, et al. Percutaneous transhepatic biliary stenting: the first experience and results of the Hospital of Kaunas University of Medicine. Med (Kaunas) 2008; 44: Robson PC, Heffernan N, Gonen M, et al. Prospective study of outcomes after percutaneous biliary drainage for malignant biliary obstruction. Ann. Surg. Oncol. 2010; 17: Cozzi G, Severini A, Civelli E, et al. Percutaneous transhepatic biliary drainage in the management of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts. Cardiovasc. Intervent. Radiol. 2006; 29 (3):380-8 Page 17 of 17