Current Status of Percutaneous Transhepatic Biliary Drainage in Palliation of Malignant Obstructive Jaundice: A Review

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1 Review Article Current Sttus of Percutneous Trnsheptic Biliry Dringe in Pllition of Mlignnt Ostructive Jundice: A Review SH Chndrshekhr, S Gmngtti, Anurdh Singh, Sushm Bhtngr 1 Deprtments of Rdio dignosis nd 1 Onco nesthesiology nd Pllitive Cre, All Indi Institute of Medicl Sciences, New Delhi, Indi Address for correspondence: Dr. SH Chndrshekhr; E mil: drchndruiims@yhoo.com ABSTRACT Mlignncies leding to ostructive jundice present too lte to perform surgery with curtive intent. Due to inexorly progressing hyperiliruinemi with its consequent deleterious effects, dringe needs to estlished even in dvnced cses. Percutneous trnsheptic iliry dringe (PTBD) nd endoscopic retrogrde cholngiopncretogrphy (ERCP) re widely used pllitive procedures ech with its own merits nd lcune. With the current stte of the rt PTBD technique consequent upon procedurl nd hrdwre improvement, it is equling ERCP regrding technicl success nd complictions. In ddition, there is reduction in immedite procedure relted mortlity with proven survivl enefit. Nonetheless, it is the only imminent lifesving procedure in cholngitis nd sepsis. Key words: Biliry stenting, Endoscopic retrogrde cholngiopncretogrphy, Ostructive jundice, Percutneous trnsheptic iliry dringe INTRODUCTION Ostructive jundice cn e of enign nd mlignnt etiologies. Of the mlignnt cuses, crcinom gll ldder, cholngiocrcinom, pncretic denocrcinom, metstsis, nd lymph nodl compression of common ile duct (CBD) constitute the mjority of cses. [1] Most of the cses of mlignnt ostructive jundice re lredy dvnced nd unresectle y the time they re dignosed, hence crry disml prognosis with pllition eing the only option left. Ostruction needs to e drined even in such cses for llevition of pin, cholngitis, nd pruritus or in certin cses to initite chemo or intriliry rchytherpy. Over the yers, Quick Response Code: Access this rticle online Wesite: DOI: / pllitive cre hs evolved with the introduction of newer methods nd improvistion of existing techniques. Recent pllitive mesures not only prolong longevity ut lso improve the qulity of life, hence incresing the cceptnce to such procedures. [1 3] Methods of iliry dringe include:. Surgicl ypss. Minimlly invsive procedures Endoscopic retrogrde cholngiopncretogrphy (ERCP) Percutneous trnsheptic iliry dringe (PTBD). This is n open ccess rticle distriuted under the terms of the Cretive Commons Attriution-NonCommercil-ShreAlike 3.0 License, which llows others to remix, twek, nd uild upon the work non-commercilly, s long s the uthor is credited nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com How to cite this rticle: Chndrshekhr SH, Gmngtti S, Singh A, Bhtngr S. Current sttus of percutneous trnsheptic iliry dringe in pllition of mlignnt ostructive jundice: A review. Indin J Pllit Cre 2016;22: Indin Journl of Pllitive Cre Pulished y Wolters Kluwer - Medknow

2 Both ERCP nd PTBD re well estlished nd effective mens of iliry dringe for pllition in unresectle cses. With incresed technicl success rte nd expertise in these minimlly invsive procedure, recent time hs witnessed n exemplry surge in the demnd for such procedure over surgicl ypss. Selecting n option over other; however, is multidisciplinry opinion, which not only involves expertise of opertor nd the site of ostruction ut lso tkes into considertion other fctors such s expected survivl nd the level of postprocedurl cre provided to the ptients. ERCP is usully performed in cses of distl CBD lock (eyond hilum) PTBD is preferred in proximl iliry ostruction. [1 3] Bismuth Corlette clssifiction [Tle 1] is used worldwide for the clssifiction of hilr cholngiocrcinom, which is sed on the sttus of primry nd secondry confluence. In this review rticle, uthors discuss vrious intriccies of PTBD including iliry stenting nd comprison with other iliry dringe options. PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE PTBD is n imge guided procedure which cn e performed under fluoroscopy or comined ultrsound nd fluoroscopic guidnce. Its indictions re vried including oth ostructive s well s nonostructive etiologies. Indictions of PTBD for pllition in ostructive jundice include: Cholngitis Pin llevition Pruritus To decrese serum iliruin efore the initition of chemotherpy To ccess iliry system for further pllitive interventions such s stent plcement or trnsheptic rchytherpy for cholngiocrcinom. Tle 1: Bismuth-Corlette clssifiction for hilr cholngiocrcinom Type I II III III III IV Finding Proximl CHD/CBD lock: Primry confluence ptent Primry confluence locked, secondry ptent Secondry confluence locked (unilterl) Right secondry confluence locked Left secondry confluence locked Bilterl secondry confluence locked CBD: Common ile duct; CHD: Common heptic duct Elevted serum iliruin (>3 g/dl) cliniclly presents s jundice. Hyperiliruinemi impedes the initition/continution of chemotherpy in certin mlignncies. Pruritus is common ccompniment in mlignnt ostructive jundice which my e disproportionte to the jundice nd usully llevited y the dringe of even single liver segment. Pin nd norexi further deteriorte the qulity of life which my e relieved to some extent y restoring physiologicl enteroheptic circultion y vrious dringe mens (vide supr). [4 7] CONTRAINDICATIONS Asolute o Uncorrectle leeding dithesis. Reltive o INR >1.5 o Pltelet counts <50,000 o Ascites o Multiple heptic cysts. [8] PREPROCEDURAL PATIENT S PREPARATION 1. Adequte ntiiotic coverge (preferly intrvenous) should e instituted efore nd fter the procedure, s mnipultions in ostructed system crry the risk of cholngitis nd sepsis 2. For pin llevition, intrvenous nlgesics cn e dministered or optionlly the procedure cn e performed under conscious sedtion 3. Ptient should e preferly fsting or on cler liquid diets for t lest 4 h prior to the procedure. TECHNIQUE Selection of pproprite trget duct for iliry dringe Prior to the initition of procedure, three dimensionl cross sectionl imging, i.e. computed tomogrphy or mgnetic resonnce imging of the ptient needs to e reviewed to determine the following: 1. Site of ostruction high or low. In proximl ostruction, primry iliry confluence my e locked with vrile involvement of secondry confluence. Low ostruction occurs eyond the level of primry iliry confluence (i.e., distl to cystic duct insertion). PTBD nd ERCP re the preferred dringe Indin Journl of Pllitive Cre / Oct-Dec 2016 / Vol 22 / Issue 4 379

3 procedures in high nd low iliry ostructions, respectively 2. Selection of pproprite trget duct in PTBD right versus left PTBD In cse of involvement of iliry confluence, selected duct should drin t lest one sixth of the liver prenchym. However, in distl ostruction, since primry iliry confluence is ptent, single puncture with plcement of single dringe ctheter usully suffices There should e no trophy or portl vein involvement of the trgeted loe s even fter iliry dringe, liver function would not improve due to the lck of functioning heptic prenchym. PTBD shll e formidle when cross sectionl imging is not reviewed due to the oserved lesser technicl success rte of the procedure. [1,3] The procedure cn e performed either vi right (sucostl or intercostl) or left ductl (suxiphoid) pproch. Selection of pproprite sided duct (right or left) is personl preference, lthough there re certin dvntges nd disdvntges of oth [Tles 2 nd 3]. Reviewing ultrsound prior to iliry puncture is invlule for ssessing the suitility of puncture s well s ny contrindiction to the procedure [Figure 1]. Left sided percutneous trnsheptic iliry dringe In cse of suitly dilted iliry rdicle dilttion, with n 18G puncture needle, under ultrsound guidnce, pproprite segmentl duct is punctured. In portl trid, iliry rdicle is flnked y the rnch of heptic rtery nd portl vein, clier of which increses towrd the heptic hilum. Due to this, site of puncture should e s peripherl s possile s more centrl puncture incurs more risk of mjor vsculr injury [Figure 2]. When the outflow of ile strts, inch hydrophilic guide wire is pssed through the puncture needle. Further, the mlignnt stricture is negotited with the help of ngiogrphic ctheters nd hydrophilic guide wires. During the procedure, intermittent check cholngiogrms re done whenever needed to mp the iliry ntomy, site of ostruction, nd position of guide wire nd ctheters, keeping the contrst volume nd concentrtion to minimum. In cses where the site of iliry ostruction is negotited, ring iliry ctheter (8.3 Fr) is left on comined externl nd internl dringe for the initil few dys with its tip in the duodenum eyond the mpull [Figure 3]. After estlishment of successful dringe, ctheter is cpped externlly nd left solely on internl dringe. In situtions when the site of ostruction is not crossed, externl dringe ctheter is left in the iliry system for its decompression. Further ttempts for internliztion re done once there is reduction in the degree of iliry dilttion nd susidence of edem (usully fter 3 7 dys). Internliztion is desirle s it restores the physiologicl enteroheptic circultion, thus preventing the loss of ile slts. Benefits nd drwcks of left sided PTBD re tulted elow [Tle 2]. Right sided percutneous trnsheptic iliry dringe Initil puncture is fluoroscopiclly guided, site is elow the tenth ri in mid xillry line (with 10 forwrd nd crnil Tle 2: Merits nd demerits of left sided percutneous trnsheptic iliry dringe Advntges Reltively esier to perform Better ptient s complince Preferred in scites (due to reltively less perictheter lek of scites) Disdvntges More rdition exposure to performer s hnd Tle 3: Merits nd demerits of right sided percutneous trnsheptic iliry dringe Advntges Less rdition exposure to the hnds of performers More segments of liver covered Disdvntges More pinful due to continuous irrittion of intercostl nerves More chnces of ccidentl slippge due to constnt motion of the dringe ctheter in the intercostl spce during respirtion c Figure 1: Ultrsound in preprocedurl workup () determining the level of ostruction nd degree of intrheptic iliry rdicl dilttion: Ultrsonogrphy domen showing n ill defined heterogeneously hypoechoic mss (rrow) t the port heptis locking primry nd ilterl secondry confluences with iliry rdicles dilted till periphery (curved rrow), suitle for ultrsound guided puncture, () Selection of trget loe: Excluding lor trophy (rrow) nd portl venous thromosis, (c) ruling out scites (rrow), which is reltive contrindiction 380 Indin Journl of Pllitive Cre / Oct-Dec 2016 / Vol 22 / Issue 4

4 Figure 2: Approch to percutneous trnsheptic iliry dringe () right percutneous trnsheptic iliry dringe: Cse of hilr cholngiocrcinom: the right intrheptic iliry rdicl punctured elow the 10 th ri to void pleur. After internliztion with its distl tip in duodenum (rrow). Check cholngiogrm showed opcifiction of ilor intrheptic iliry rdicl nd duodenum suggesting optiml plcement, () left percutneous trnsheptic iliry dringe: Cse of perimpullry crcinom with filed endoscopic stent plcement. Dilted left intrheptic iliry rdicl punctured with negotition of stricture nd susequent plcement of ring iliry ctheter (rrow) ngultion of needle tip) to ovite pleurl injury. Then, under fluoroscopic guidnce, puncture needle is dvnced for length of pproximtely 3 4 cm, following which ultrsound guidnce is resorted for further directing the needle to pproprite segmentl duct. Remining steps re similr s mentioned in the left PTBD (vide supr). A comprison of dvntges nd disdvntges of right sided PTBD is compred elow [Tle 3 nd Figure 2]. Postprocedurl cre Ptient should e dmitted for dy to look for potentil mjor complictions, especilly sepsis nd hemoili with continution of ntiiotics [Figure 4]. COMPLICATIONS OF PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE With incresed expertise nd etter instrumenttion, oserved technicl success rte of PTBD is ~90 95% with fewer complictions oserved nowdys. These complictions cn e further reduced y keeping the iliry mnipultion to minimum nd good ntiiotic coverge. [9] Minor Pin Perictheter lek. Mjor Cholngitis, sepsis Biliry peritonitis Hemorrhge Pncretitis. c Figure 3: Types of iliry dringe: () Externl dringe: HC with proximl common heptic duct ostruction. Left percutneous trnsheptic iliry dringe done, () unilterl internl externl dringe: C GB with ilor intrheptic iliry dilttion mnged y the left percutneous trnsheptic iliry dringe nd externl internl ctheter plcement, (c) ilterl internl externl dringe: HC with primry iliry confluence exclusion mnged y ilterl percutneous trnsheptic iliry dringe nd ntegrde ctheter plcement, (d) internl dringe y endoprosthesis: C GB locking primry iliry confluence. After initil percutneous trnsheptic iliry dringe, SEMS ws plced. (HC: Hilr cholngiocrcinom, C GB: Crcinom gll ldder, SEMS: Self expndle metllic stent) Pleurl effusion, pneumothorx (indvertent pleurl puncture). Ctheter dislodgement is more common in externl thn internl dringe ctheters due to etter nchorge in the ltter. It cn e mnged y repositioning or proing y guide wire [Figure 5] through previous ctheter s trct. [10] Perictheter lek (ile lek long ctheter) is frequently oserved compliction [Figure 6]. It cn e due to side holes of ctheter lying outside the iliry system, ctheter kink/lock, or scites. Mngement in such cses consists of ctheter repositioning or upgrdtion depending on the findings of check cholngiogrm. Cholngitis nd iliry sepsis re inevitle complictions which cn occur despite dequte ntiiotic coverge. Although exct etiology is unknown, it cn occur due to multitude of fctors such s retrogrde reflux of intestinl flor during the procedure, ex vitro infection trcking long the dringe ctheter, or my e of hemtogenous origin. Prophylcticlly, rod spectrum intrvenous ntiiotics covering Grm-negtive cteri should e instituted. In ddition, during the procedure, mnipultions should e kept to minimum coupled with limited use of iodinted contrst during per procedurl cholngiogrphy. Symptomtic mngement should e done in such cses y continuing the ntiiotics nd mintining the fluid lnce. [1,10] d Indin Journl of Pllitive Cre / Oct-Dec 2016 / Vol 22 / Issue 4 381

5 Figure 4: Postprocedurl mngement lgorithm fter percutneous trnsheptic iliry dringe Figure 5: Ctheter dislodgement nd repositioning () postopertive cse of crcinom gll ldder with recurrence t port heptis cusing ostruction of proximl common ile duct, primry nd ilterl iliry confluences were ptent. Due to hyperiliruinemi, the left percutneous trnsheptic iliry dringe ws performed with the plcement of internl externl ctheter. Lter on, due to decresed ctheter output nd perictheter lek, cholngiogrm ws done which reveled dislodgement of the ctheter with its migrted tip in the left sided iliry rdicle (rrows), () susequently, guide wire mnipultion ws done nd mlignnt stricture ws negotited, following which tip of the ctheter ws repositioned into the duodenum (rrow in ) Figure 6: () Perictheter lek fter the right percutneous trnsheptic iliry dringe for crcinom gll ldder. Cholngiogrm showed sliver of contrst long the right loe of liver (rrow) s few side holes of dringe ctheter were outside the iliry tree. After ctheter repositioning, perictheter lek susided, () leed inside the iliry tree following percutneous trnsheptic iliry dringe: Perimpullry crcinom with locked endoscopic retrogrde cholngiopncretogrphy stent (*). Right sided percutneous trnsheptic iliry dringe done. Postprocedurl check cholngiogrm showed irregulr cst like filling defects in common ile duct nd left ductl system with meger pssge of contrst through its distl tip (curved rrow) into the duodenum s/o hemoili Hemorrhge/hemoili fter PTBD is usully trnsient nd is less commonly seen with more peripherl iliry rdicle puncture [Figure 6]. As heptic rtery nd portl vein lso ccompny the dilted iliry rdicle, side holes of the dringe ctheter my get positioned in these vsculr structures, which cn e corrected y ctheter repositioning. [1,3] Sudden onset or hemoili occurring 1 2 weeks fter the procedure is usully due to rteril injury (ctive extrvstion or pseudoneurysm), especilly if it is pulstile nd there is perictheter hemorrhge. Angiogrphy needs to e done in such cses followed y emoliztion of leeding rtery [Figure 7]. [3] c Figure 7: Post percutneous trnsheptic iliry dringe leed due to pseudoneurysm: () Crcinom gll ldder with ilor intrheptic iliry dilttion. Two weeks fter right percutneous trnsheptic iliry dringe nd externl dringe ctheter plcement in common heptic duct (curved rrow), the ptient presented with shock nd frnk pulstile leeding. Celic xis (rrow) ngiogrm showed no contrst extrvstion or pseudoneurysm (*ngiogrphic ctheter) () superselective ctheteriztion of the left heptic rtery reveled pseudoneurysm (rrows) (c) exclusion of pseudoneurysm with coil emoliztion (rrow) (d) postprocedurl ngiogrphy showing olitertion of pseudoneurysm (rrow) In oth proximl nd distl iliry ostructions, PTBD complictions re similr; however, incidence is higher in cses of proximl (hilr) lock due to following resons 1. Incresed risk of cholngitis: Due to indvertent contrst injection into nondrining segment during cholngiogrms 2. Less technicl success: PTBD is more demnding in hilr lock with lesser chnces of internliztion d 382 Indin Journl of Pllitive Cre / Oct-Dec 2016 / Vol 22 / Issue 4

6 in the first ttempt nd incresed risk of ctheter dislodgement. [1] BILIARY STENTING Biliry stenting cn e performed endoscopiclly, percutneously, or y the comined mens. Biliry stents cn e either plstic or metllic, selection of which depends on the etiology of iliry ostruction (enign vs. mlignnt), life expectncy, nd ffordility. Metllic stents In cses which im pllition such s unresectle mlignncies, self expndle metllic stents (SEMS) re preferred for permnent stenting over plstic stents due to etter ptency. If there is occlusion of stent due to tumor ingrowth, then nother stent or externl/internl dringe ctheter cn e plced through it without the need of removl. [1,3,11,12] Percutneous iliry stenting should e contemplted s stged procedure fter initil iliry decompression when there is susidence of risk of cholngitis/sepsis. After few dys (out week or lter) of preliminry decompression, check cholngiogrm is done to look for degree of iliry dilttion s well s site of stent plcement. In conducive situtions, stents re plced into the iliry system covering the tumor. Susequent to the successful stenting, percutneous trnsheptic dringe ctheter is removed, thus lleviting the ctheter relted potentil complictions (vide supr). [1] SELECTION OF BILIARY RADICLE/SEGMENT FOR ADEQUATE BILIARY DRAINAGE: DIFFERENCE IN APPROACH IN CATHETER DRAINAGE VERSUS METALLIC BILIARY STENTING As mentioned vide supr tht for percutneous ctheter dringe, selection of iliry ccess (right vs. left) depends on the volume of loe, sttus of portl vein nd cholngitis. Due to its lrge volume, usully, the right PTBD is preferred with n intent to slvge the functioning liver prenchym. However, the right segmentl ducts re shorter s compred to the left sided ducts. As corollry, further growth of mlignncies will led to proportiontely more severe involvement of the right duct. In generl, depending on the type of hilr lock, the following pproch is followed [Tle 4] for stent plcement. [13,14] Types nd configurtion of metllic iliry stenting Required numer nd configurtion of stents depend on the degree (primry vs. secondry iliry confluence lock) of iliry ostruction nd the presence of cholngitis [Figure 8]. 1. Single stent when the site of ostruction is t or eyond the level of primry iliry confluence. If primry iliry confluence is ptent, stenting cn e done either from right or left sided ductl ccess. However, if primry confluence is locked, stent should e plced through the side eing more ffected or drins lrger segment of liver 2. Bilterl stents They re indicted when secondry confluence (either unilterl or ilterl) is locked (Bismuth Corlette III nd IV) 3. Multiple stents They my e required in Type IV lock when more thn one mjor segmentl duct s dringe is required to lower iliruin or if cholngitis ensues. [11,12,15] Configurtion of iliry stents Most of the iliry trct mlignncies re usully mnged y single stent, especilly when primry confluence is ptent. However, when there is isoltion of right nd left segmentl ducts, dequte iliry dringe my require ilterl stenting. Biliry stenting contemplted in hilr mlignncies (Type IV lock) for ilterl iliry dringe cn e configured in two wys Y nd T configurtion [Figure 9]. [12,15] Y shped It is the most preferred stent configurtion in which ilterl (oth right- nd left-sided) percutneous iliry Figure 8: Types of iliry stenting () Single stent: crcinom gll ldder with locked primry iliry confluence. Single stent (rrows) plced through the left ductl pproch () ilterl stents: Performed in locked secondry iliry confluences (unilterl or ilterl). Two iliry stents (rrow) seen encompssing the hilum, drining the left nd right nterior sectorl duct (c) multiple stents: Type IV hilr cholngiocrcinom cusing isoltion of mjor segmentl ducts. Stents cn e seen drining left, right nterior, nd posterior sectorl ducts into common ile duct. One of the stents is seen drining into duodenum (curved rrow) c Indin Journl of Pllitive Cre / Oct-Dec 2016 / Vol 22 / Issue 4 383

7 Tle 4: Selection of percutneous iliry ccess for stent deployment on the sis of type of lock Type of hilr lock (Bismuth- Corlette clssifiction) I, II Left III, III IV CBD: Common ile duct ccess is chieved. The first stent is then plced through one of the ccess with its proximl nd distl tip in the ipsilterl heptic duct nd duodenum, respectively. After this, with the contrlterl iliry ccess, other SEMS is introduced through the mesh of the first one with its positioning remining sme; however, its proximl tip is in the contrlterl heptic duct. This configurtion ims to restore the norml iliry ntomy for dringe. T shped In this configurtion, ilterl stenting cn e performed even through the unilterl iliry ccess. Here, for instnce if left PTBD is done, the first SEMS is plced in horizontl configurtion from left to right heptic duct. The second SEMS is then plced connecting the trnsverse stent to the CBD in verticl configurtion. Although T configurtion offers the dvntge of ilor dringe through single puncture; however, in cse of stent lock, susequent re intervention is comprtively esier in the Y configurtion. Plstic stents Plstic stent is preferred in enign cuses s it cn e retrieved susequently which is not the option in metllic stents. In certin mlignncies such s lymphom (leding to iliry ostruction) or in hilr lock with multiple isolted iliry segments, plstic stenting cn e done. [15] Complictions of iliry stenting Duct selection for stent deployment If single stent left Doule stent left nd right nterior/posterior Two stents plced Stent 1: Left duct hilum right nterior Stent 2: Right posterior duct CBD duodenum Aprt from the possile complictions of initil PTBD (mentioned ove), specific stent relted dversities my occur which re usully delyed events such s stent occlusion, lock, or migrtion. Stent occlusion occurs due to either tumor ingrowth through its struts or tumor overgrowth either proximl or distl to the stent. Compring the likelihood of occlusion of plstic nd metllic stents, the ltter scores with its longer ptency rtes [Tle 5]. [13,14,16] Medin ptency of the iliry stents depends on its type, i.e., plstic versus metllic, covered or uncovered, its clier, Figure 9: Configurtion of metllic iliry stents () Y shped: Initil ilterl percutneous iliry ccess followed y the deployment of metllic stent ilterlly. Performed in Type III or IV lock () T-shped: Left sided percutneous ccess ws gined followed y plcement of the first stent horizontlly from left to right heptic duct cross the hilum. Another stent is then plced verticlly through the mesh of the previous one connecting the trnsverse/ horizontl stent to the CBD. Inset in A nd B depicting pictoril representtion. Y configurtion is preferred in cute hilr ngle wheres T configurtion is preferred in otuse hilr ngle site of mlignnt occlusion, nd concomitnt intrluminl rchytherpy dministrtion. In generl, if stenting ims pllition, then plstic stents re used if expected survivl is <3 4 months, otherwise metllic stents re used s the former is reltively cheper. In most series, 30 dy mortlity is >10%, medin survivl eing 10 months, nd most ptients die due to the underlying mlignncy. Men ptency rte of SEMS is 6-9 months with n occlusion rte of 30 40% y 6 months. Stent occlusion requiring re intervention occurs in ~10 30% of the cses. [11,12,15,17] In study conducted y one of the uthors, medin stent ptency ws 147 dys. In generl, ptency rte of stent is higher thn internl externl dringe (ring iliry) ctheter likely due to its lrger clier, less chnces of lockge due to infections s they re not exposed externlly, nd no ccidentl dislodgement unlike ring iliry ctheter. [17] The cost of procedure including hospitliztion vries from hospitl to hospitl, whether government or privte. The cost of iliry stent is pproximtely 30,000 70,000 Indin rupees. The cost of hrdwre (other thn stent) for PTBD procedure is pproximtely 10,000 15,000 Indin rupees. Hospitliztion chrges vry significntly from government to privte hospitls or centers. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY ERCP with plcement of plstic stent (polyethylene endoprosthesis) is nother effective method of iliry 384 Indin Journl of Pllitive Cre / Oct-Dec 2016 / Vol 22 / Issue 4

8 dringe. It is the preferred procedure in cses of ostruction eyond the level of hilum, i.e. if the primry iliry confluence is ptent s dequte iliry dringe cn e ccomplished y the plcement of single stent. Furthermore, in such cses of low iliry ostruction, ERCP is preferred, s it is sfer procedure in comprison to PTBD. [18 20] Asolute CONTRAINDICATIONS TO ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY Phryngel or esophgel ostruction (s endoscope cnnot e dvnced) Active cogulopthy. [21,22] Reltive Acute pncretitis Severe crdiopulmonry disese Filure to cnnulte duodenl ppill: Previous roux en Y surgery (distortion of mpullry ntomy) nd duodenl stenosis. ENDOSCOPIC (ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY) VERSUS PERCUTANEOUS DRAINAGE (PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE) In inoperle mlignncies cusing iliry ostruction, ERCP with plcement of plstic endoprosthesis or PTBD with metllic stenting remins the minimlly invsive options. However, choosing procedure over other depends on the level of ostruction, opertor s expertise, nd the level of postprocedurl cre provided to the ptient. Tle 5: Metllic versus plstic stents Prmeters Metllic stents Plstic stents Long term ptency More Lesser due to higher rte of tumor ingrowth Scope for revision in stent occlusion More s nother stent or dringe ctheter cn e plced Clier of trnsheptic trct through liver (Fr) Complictions like stent migrtion, side rnch occlusion Less s it needs to e tken out surgiclly Smller (6/7) Lrger (10) More Less Cost More Less Distl iliry ostruction ERCP is unmiguously the preferred procedure worldwide s it is comprly sfer procedure with reltively fewer contrindictions. Unlike PTBD, urden of percutneous dringe ctheter nd g is ovited which further compounds the psychologicl urden of terminlly ill ptients. In the current scenrio, in cses of distl CBD ostruction, ERCP is the preferred technique unless contrindicted (vide supr), for which PTBD is done. [23,24] Proximl iliry ostruction Opinion is divided regrding the choice of technique with nerly comprle results regrding overll ptient s survivl nd procedure relted compliction. However, t mny institutions, PTBD is preferred in hilr isoltion s ultrsound guided puncture of pproprite segmentl iliry rdicle cn e done, thus mximizing the dringe of functioning liver prenchym. Further, mlignnt stricture is etter negotited in PTBD nd the risk of indvertent contrst instilltion into isolted iliry segment is lesser s compred to ERCP. [3,17,25 27] Vrious studies compring PTBD nd ERCP in distl CBD lock hve reported tht oth these procedures hve nerly equivlent technicl success rte with comprle incidences of procedure relted complictions nd mortlity [Tle 6]. [1] The Americn College of Rdiology (ACR) hs recently proposed n evidence sed lgorithmic pproch for rdiologicl mngement of mlignnt iliry ostruction. In the proposed criteri, vrious mngement options re rted sed on their ppropriteness for prticulr site of ostruction [Tle 7]. In generl, s per the ACR recommendtions of the vrious mngement options, PTBD is preferred for hilr lock wheres ERCP with stenting in distl lock. ACR Appropriteness Criteri : Mngement of Benign nd Mlignnt Biliry Ostruction, 2012 review [Tle 8]. CONCLUSION Due to recent dvnces in the procedurl technique coupled with etter hrdwre s vilility, there hs een significnt reduction in the overll moridity nd mortlity (short term) in cses of mlignnt ostructive jundice. However, long term prognosis remins disml in mlignnt ostructive jundice due to relentless drgging evolution of primry mlignncy. Nonetheless, in the current scenrio, PTBD is the recommended stndrd of pllitive cre for Indin Journl of Pllitive Cre / Oct-Dec 2016 / Vol 22 / Issue 4 385

9 Tle 6: Comprison of endoscopic retrogrde cholngiopncretogrphy nd percutneous trnsheptic iliry dringe Level of ostruction cses of ostructive jundice s it improves the qulity of life with definite immedite survivl enefits. Finncil support nd sponsorship Nil. Conflicts of interest ERCP with plstic endoprosthesis There re no conflicts of interest. REFERENCES Biliry dringe procedure PTBD Proximl/hilr Preferred Preferred (±stent) Distl Technicl success Comprle Comprle Overll mortlity No significnt difference No significnt difference Mjor locl compliction Pncretitis Biliry lek Pinful Less More Externl dringe g Not required Required in cses of unsuccessful internliztion ERCP: Endoscopic retrogrde cholngiopncretogrphy; PTBD: Percutneous trnsheptic iliry dringe Tle 7: Americn College of Rdiology ppropriteness criteri for rdiologicl mngement of mlignnt iliry ostruction Mngement options Hilr lock Rting in Distl CBD ostruction Endoscopic internl iliry ctheter 6 8 Percutneous internl/externl iliry ctheter Surgery (trnsplnt or heptico jejunostomy) Permnent iliry metllic stent 6 5 Removle iliry covered stent 5 5 Endosonogrphy guided iliry dringe 3 4 Medicl mngement only 2 3 Rting scle: 1, 2, 3 usully not pproprite; 4, 5, 6 my e pproprite; 7, 8, 9 usully pproprite. CBD: Common ile duct Tle 8: Recommendtions for iliry dringe in pllitive cre Proximl iliry ostruction (hilr involvement) PTBD or ERCP Distl (eyond hilum) ostruction: ERCP preferred Inoperle cses with short life expectncy (6 12 months) Metllic iliry stenting 1. vn Delden OM, Lméris JS. Percutneous dringe nd stenting for pllition of mlignnt ile duct ostruction. Eur Rdiol 2008;18: Crosr Teixeir M, Mk MP, Mrques DF, Cpreli F, Crnevle FC, Moreir AM, et l. Percutneous trnsheptic iliry dringe in ptients with dvnced solid mlignncies: Prognostic fctors nd clinicl outcomes. J Gstrointest Cncer 2013;44: Covey AM, Brown KT. Percutneous trnsheptic iliry dringe. Tech Vsc Interv Rdiol 2008;11: Arhm NS, Brkun JS, Brkun AN. Pllition of mlignnt iliry ostruction: A prospective tril exmining impct on qulity of life. Gstrointest Endosc 2002;56: Bllinger AB, McHugh M, Ctnch SM, Alsted EM, Clrk ML. Symptom relief nd qulity of life fter stenting for mlignnt ile duct ostruction. Gut 1994;35: Vn Lethem JL, De Broux S, Eisendrth P, Cremer M, Le Moine O, Devière J. Clinicl impct of iliry dringe nd jundice resolution in ptients with ostructive metstses t the hilum. Am J Gstroenterol 2003;98: Pdillo FJ, Andicoerry B, Nrnjo A, Miño G, Per C, Sitges Serr A. Anorexi nd the effect of internl iliry dringe on food intke in ptients with ostructive jundice. J Am Coll Surg 2001;192: Morgn RA, Adm A. Percutneous mngement of iliry ostruction. In: Gzelle GS, Sini S, Mueller PR, editors. Heptoiliry nd Pncretic Rdiology Imging nd Intervention. New York: Thieme; p Burke DR, Lewis CA, Crdell JF, Citron SJ, Drooz AT, Hskl ZJ, et l. Qulity improvement guidelines for percutneous trnsheptic cholngiogrphy nd iliry dringe. J Vsc Interv Rdiol 2003;14(9 Pt 2):S Xu C, Hung XE, Wng SX, Lv PH, Sun L, Wng FA. Comprison of infection etween internl externl nd externl percutneous trnsheptic iliry dringe in treting ptients with mlignnt ostructive jundice. Asin Pc J Cncer Prev 2015;16: Rossi P, Bezzi M, Rossi M, Adm A, Chetty N, Roddie ME, et l. Metllic stents in mlignnt iliry ostruction: Results of multicenter Europen study of 240 ptients. J Vsc Interv Rdiol 1994;5: Slomonowitz EK, Adm A, Antonucci F, Stuckmnn G, Zollikofer CL. Mlignnt iliry ostruction: Tretment with self expndle stinless steel endoprosthesis. Crdiovsc Intervent Rdiol 1992;15: Lee MJ, Dwson SL, Mueller PR, Hhn PF, Sini S, Lu DS, et l. Filed metllic iliry stents: Cuses nd mngement of delyed complictions. Clin Rdiol 1994;49: Lméris JS, Stoker J, Nijs HG, Zonderlnd HM, Terpstr OT, vn Blnkenstein M, et l. Mlignnt iliry ostruction: Percutneous use of self expndle stents. Rdiology 1991;179: Wgner HJ, Knyrim K, Vkil N, Klose KJ. Plstic endoprostheses versus metl stents in the pllitive tretment of mlignnt hilr iliry ostruction. A prospective nd rndomized tril. Endoscopy 1993;25: Stoker J, Lméris JS. Complictions of percutneously inserted iliry Wllstents. 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10 24. Vn Leeuwen DJ, Huiregtse K, Tytgt GN. Crcinom of the heptic confluence 25 yers fter Kltskin s description: Dignosis nd endoscopic mngement. Semin Liver Dis 1990;10: Nggr E, Krg E, Mtzen P. Endoscopiclly inserted iliry endoprosthesis in mlignnt ostructive jundice. A survey of the literture. Liver 1990;10: Wlt DC, Fusel CS, Brnt B. Endoscopic iliry stents nd ostructive jundice. Am J Surg 1987;153: Kufmn SL. Percutneous pllition of unresectle pncretic cncer. Surg Clin North Am 1995;75: Indin Journl of Pllitive Cre / Oct-Dec 2016 / Vol 22 / Issue 4 387