Interventional Radiology Rounds:

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1 1295 Interventional Radiology Rounds: University of California, San Francisco Percutaneous Biliary Drainage in the Management of Cholangiocarcinoma Robert K. Kerlan, Jr., Moderator1 Anton C. Pogany2 Henry I. Goldberg1 Ernest J. Ring1 This is the first of periodic selections from the Interventional Radiology Rounds of the University of California, San Francisco. They feature the staff and guests of the Department of Radiology, discussing particularly instructive cases where the diagnostic radiologist assumes a role in managing the patient s disease. Dr. Kerlan. A 59-year-old man was admitted after a 20- day history of epigastnic pain accompanied by episodes of fever and chills, progressive jaundice, and light stools. He had no history of biliary calculi on other medical disease. Sonognaphy demonstrated dilatation of the intrahepatic biliary ducts. A computed tomognaphic (CT) examination confirmed this finding, but failed to demonstrate a mass in the porta hepatis or pancreas. No intrahepatic masses were detected. To assess the precise level of biliary obstruction in anticipation of surgical decompression, percutaneous transhepatic cholangiography was performed. Because of the history of fever and chills, and the risk of precipitating severe biliary sepsis, the patient was given intravenous broad-spectnum antibiotics for 24 hr before the procedure. Dr. Goldberg, would you comment on this study? Dr. Goldberg. A thin-needle percutaneous transhepatic cholangiogram showed obstruction at the convergence of the main left and two main night branches of the biliary ductal system. There was partial filling of the proximal left duct, indicating continuity between the left and night systems (fig. 1 A). These findings were believed to be most compatible with cholangiocarcinoma. The biliary tree was aspirated, and soon after the study, lapanotomy was pefonmed. A cholangiocarcinoma was found at the bifurcation of the common hepatic duct, extending into the porta hepatis. The surgeons considered the tumor unnesectable and placed a I-tube in the common duct. Dr. Ring. Dr. Goldberg, this man was operated on without preoperative biliary drainage. What are your thoughts on presungical management of obstructive jaundice and infection in the biliary tree? Dr. Goldberg. A patient proven to have complete biliary obstruction by a percutaneous transhepatic cholangiogram, whether or not he has any sepsis, should have drainage percutaneously before surgery. Not to do so after the injection of contrast medium under pressure is to court the risk of septic shock. In this patient, injection and aspiration were done through the skinny needle. The patient went to surgery very soon thereafter (although not the same day) and, in my opinion, an external drainage catheter should have been placed. It is very important that the physician performing the percutaneous transhepatic cholangiogram, whether sungeon, gastroenterologist, or radiologist, be prepared to institute external drainage for high-grade or complete obstruction. Received January 24, 1983; accepted after revision July 1 9, 1983., Department of Radiology, University of California School of Medicine, San Francisco, CA Address reprint requests to R. K. Kerlan, Jr. 2 Department of Radiology, Veterans Administration Medical Center, San Francisco, CA AJR 141 : , December X/83/ American Roentgen Ray Society

2 1296 KERLAN ET AL. AJR:141, December 1983 D E F Fig. 1 -A, Percutaneous transhepatic cholangiognam. Complete obstruction of the common hepatic duct and high-grade narrowing near junction of right and left hepatic ducts. Left hepatic ductal system is faintly seen (arrowheads). B, Cholangiogram obtained by injection of percutaneous transhepatic drainage catheter. Both night and left hepatic ductal systems are seen. Drainage catheter terminates in transverse duodenum. C, Follow-up tube cholangiogram no longer demonstrates filling of left hepatic ductal system. Right system appears to be adequately decompressed. D, 1 0 French trans- purulent, it can be aspirated through a skinny needle; but, in general, it is not very successful, and for adequate dehepatic drainage catheter extends from right into left ductal system. 12 French endoprosthesis (arrow) extends from right ductal system into duodenum. E, Late arterial phase of selective common hepatic arteriognam. Extravasation (arrowhead) from night hepatic arterial branch. No discrete false aneurysm is identified. F, Arterial phase of selective common hepatic arteniogram. Successful occlusion of night hepatic artery. Coil spring embolus can be seen in proximal part of blood vessel (arrow). Dr. Ring. Have you been successful in decompressing the biliary system through a skinny needle? Dr. Goldberg. Occasionally. If the bile is not viscous and compression, a drainage catheter is necessary. Dr. Ring. I used to believe it was an accepted surgical principle that the outlook for patients with very high levels of serum bilirubin and/on cholangitis improved if the biliary tree were drained percutaneously before surgery [1 1. How-

3 AJR:1 41, December 1983 INTERVENTIONAL RADIOLOGY ROUNDS 1297 even, this concept was recently challenged by Nonlander et al. [2]. They reviewed a nonrandomized group of patients, about half of whom were drained preoperatively, and found that the operative mortality was 1 8% with preoperative drainage and 33% among patients with obstructing tumors who were not decompressed before surgery. The difference was not considered statistically significant, and they concluded that there was no advantage to preoperative biliary drainage. Dr. Goldberg. The difference between the two groups is nearly identical to that reported in a recent Japanese series, where the opposite conclusion was reached [3]. Operative mortality in that series (death within 1 month of operation) was 8.2% of 49 patients with malignant obstruction who were drained preoperatively compared with 23% in a group of 1 48 patients without preoperative decompression. Dr. Ring. I would like to see a large randomized study that would determine unequivocally the role of preoperative biliary drainage. I have tried to develop such a study, but could not gain the cooperation of referring surgeons willing to operate on patients with high serum bilirubins without preliminary drainage procedures. Dr. Kerlan. Postoperatively, biliary drainage through the tube was slight, and the patient continued to experience recurrent fevers. A plain film of the abdomen showed a rather unusual orientation of the I-tube limbs that did not correspond to the patient s biliary anatomy. A I-tube cholangiogram demonstrated that the tube was not in communication with the biliary tree. As the tumor was determined to be unresectable at surgery and the patient was expeniencing symptoms of cholangitis, it was necessary to perform an immediate percutaneous biliary drainage. Percutaneous drainage was undertaken from a right lateral approach. Dr. Ring, how often can drainage catheters be placed successfully across obstructions in the biliary tree? Dr. Ring. In our first 1 00 patients, we were able to cross the obstruction successfully in 97, and in our last 300 cases, we have been universally successful. The improved success in traversing obstructions reflects improvement in technique and a better awareness of where to search for the tract through the obstruction. The tract often is not located at the beak of the duct above the obstruction, and, in fact, commonly can be found originating at a 90#{176} angie to the, beak. Dr. Goldberg. In a recent review of the world literature by Grelet et al. [4], 938 cases of transhepatic biliary drainage were reviewed. Reported success rates in crossing biliary obstructions averaged about 80%. In keeping with what Dr. Ring has said, that review included a number of centers reporting their first 50 cases, and there were very few papers in that series that reported experience with more than 1 00 cases. Dr. Ring. I think it is important not to attempt to cross the obstruction during the initial drainage procedure in the treatment of biliary sepsis. The drainage procedure should be performed with as little manipulation as possible, and the catheter should be left above the obstruction until the patient has stabilized. Dr. Kerlan. A postdnainage film shows an 8.3 French drainage catheter with side holes above and below the obstruction and the pigtail in the duodenum. The right-sided biliary system is less dilated (fig. 1 B). Assuming adequate biliary drainage is established, how long should one wait before capping the external part of the catheter? Dr. Goldberg. We usually place the stent and leave it to external drainage for 1-2 weeks and have the patient return then. I believe it is best not to have the patient cap the tube at home without having its position checked. I also like to be certain that the patient lives where he can be observed closely. Dr. Ring. My practice is a little different. We initially tried capping tubes at 72 hr, and found that about half of the time, it worked quite well. However, in the remaining patients, even though side holes were properly positioned and the anatomy was appropriate, antegrade drainage did not occur. The reason for failure of antegrade drainage in these patients is probably related to the physical properties of bile. Bile is a non-newtonian fluid and, therefore, flows more like catsup than water. Depending on its viscosity and the secretory pressure in the ducts, antegrade bile drainage through a 8.3 French catheter can be very unpredictable. About 2 years ago, we stopped trying to achieve antegrade drainage through this relatively small catheter. Our practice now is to drain the ducts externally through the 8.3 French catheter and discharge the patient after 2-3 days. Two weeks later, we put in either an endoprosthesis, if it is indicated, or a larger, French multi-side-hole catheten. This can be done on an outpatient basis. I don t like to hospitalize patients with advanced malignant disease any more often than is necessary, so I send them home after capping the tube, with instructions on what to look for over the next 24 hr. If antegrade drainage is insufficient, the patient will develop a fever, bile leakage around the catheter, or the return of jaundice over the next several days. If any of these symptoms occur, the patient is instructed to uncap the tube and return to the hospital. This is an uncommon occurrence with larger tubes, unless the duodenum is invaded by tumor, and the pressure relationships are such that bile cannot drain antegrade. Dr. Kerlan. The patient did well and continued to drain internally, with the tube capped, for a period of several months. Subsequently, he developed recurrent fever and chills. Dr. Pogany, would you comment on the findings of the tube cholangiogram performed at that time? Dr. Pogany. The transhepatic drainge catheter remains patent and in good position, but the left hepatic biliary tree fails to fill with contrast material, indicating interval obstruction of the left hepatic duct, almost certainly by tumor progression. The right hepatic ducts have become narrowed near their confluence, indicating tumor progression in the right hepatic lobe (fig. 1 C). Dr. Kerlan. How would you manage this problem?

4 1298 KERLAN El AL. AJR:141, December 1983 Dr. Pogany. Whenever a lesion is obstructing above the confluence of the ducts, a second drainage catheter is necessary to drain both the right and left biliary tree. The most common way to do this is to drain the left biliary tree percutaneously from an anterior approach. Alternatively, a second drainage catheter can be introduced through the existing right lateral tract and manipulated night to left across the obstruction of the left hepatic duct. An advantage of the latter procedure in this case is that it can be done on an outpatient basis. Dr. Kerlan. We decided to place a 1 2 French endoprosthesis extending from the right ductal system into the duodenum and a second 1 0 French catheter through the existing tract into the left ductal system (fig. 1 D). This allowed internal drainage of both the left and right biliary tree; the left ducts could drain into the right and then antegrade through the endoprosthesis into the duodenum. After insertion of the endoprosthesis and the right-to-left catheter, the patient did quite well for 5 months, until he again developed recurrent fevers. We instructed him to uncap the tube and drain the bile into an external drainage bag. When he did so, the tube drained blood, and he came to the emergency room. Dr. Pogany, would you comment on how you would manage the patient at this time? Dr. Pogany. The bleeding could reflect a hepatic arteryto-bile duct fistula, which could be treated by selective hepatic artery embolization, or a portal vein-to-bile duct fistula, which is usually a fatal complication. Blood replacement should be given. A tube cholangiogram sometimes will demonstrate the vascular connection. Dr. Kerlan. He was septic, as well as bleeding, at admission. I did the cholangiognam and was very disturbed when I connected a 50 ml syringe to his biliary drainage tube and obtained free return of blood, which clotted in the syringe. Under the circumstances, the first maneuver we tried was to inject the biliary system under some pressure in an attempt to opacity a blood vessel. Dr. Ring. This is a potentially dangerous procedure because of the risk of septic shock. Dr. Ker/an. We were aware of that risk, and he was placed on intravenous antibiotics. However, we believed that the attempt was warranted in view of his life-threatening hemorrhage. As you know, it is sometimes possible to occlude a hepatic artery-to-bile ductfistula through the transhepatic tract if it can be identified [5]. The cholangiogram showed clot within the biliary system but did not demonstrate the fistula. We then exchanged the indwelling drainage catheter for a 1 2 French drainage tube to tamponade the bleeding temporarily. The next day, we performed hepatic arteriography. The first hepatic artery injection, pefonmed with the 1 2 French drainage tube in place, failed to demonstrate the site of bleeding. The drainage catheter was replaced with a 5 French sheath, and a second hepatic artery injection showed extravasation into the right hepatic biliary tree (fig. 1 E). The right hepatic artery branch supplying the bleeding point was embolized with Gelfoam and a stainless steel coil (fig. 1 F). The hemobilia promptly cleaned, and the patient s fevers decreased with drainage and antibiotic therapy. A follow-up cholangiogram showed lysis of the clot within the biliary system. On discharge, the patient was draining clear bile and has been afebnile. From the onset of jaundice, this patient was managed as an outpatient for 7 months and remained anictenic. Unfortunately, he had to be hospitalized recently for massive hemotysis secondary to pulmonary metastases. Discussion This case demonstrates the difficulty of managing patients with proximal biliary tract obstructions by any technique. The great advantage of percutaneously placed catheters over surgery is the clarity that fluonoscopy provides for identifying both the intra- and extrahepatic ducts. This penmits controlled manipulations that often allow better drainage catheter positioning than can be achieved even directly at surgery. This case also points out the importance of continued care by an interventional radiology service. It is not uncommon for patients with this type of tumor to live for 2-5 years if bile flow is maintained. However, as the disease prognesses, modifications in drainage catheter positioning are often necessary to maintain bile drainage and prevent jaundice and sepsis. ACKNOWLEDGMENT We thank Gala FitzGerald for editorial assistance in manuscript preparation. REFERENCES 1. Braasch JW, Gray BN. Considerations that lower pancreatoduodenectomy mortality. Am J Surg 1977;1 29: Norlander A, Kahn B, Sundblad R. Effect of percutaneous transhepatic drainage upon liver function and postoperative mortality. Surg Gynecol Obstet 1982;1 55: , Nakayama T, Ikeda A, Okuda K. Percutaneous transhepatic drainage of the biliary tract. Gastroenterology 1 978;74 : Grelet A, Boedec C, Sabrie C, BaIp V. Drainage biliaire non chirurgical. J Radiol 1981 ;62 :

5 This article has been cited by: 1. Eric W. Olcott, Richard R. Saxon, Ernest J. Ring, Roy L. Gordon Catheter Tract Hemorrhage during Percutaneous Biliary Intervention: Management with Use of a Retained Transhepatic Guide Wire. Journal of Vascular and Interventional Radiology 6:3, [CrossRef] 2. J. Rattan A method for maintaining patency of an intracholedochal stent. Gastrointestinal Endoscopy 31:5, 350. [CrossRef]