Safety and effectiveness of ultrasound-guided percutaneous transhepatic biliary drainage: a multicenter experience

Abstract

Aims: Aim of this study is to describe a multicenter experience on percutaneous transhepatic biliary drainage (PTBD) performed with ultrasound-guidance to access the biliary tree, focusing on safety, effectiveness and radiation dose exposure; differences between right- and left-sided approaches have been also evaluated.

Methods: This is a multicenter prospective single-arm observational study conducted on patients affected by biliary tree stenosis/occlusion with jaundice and endoscopically inaccessible. The procedures have been performed puncturing the biliary system under US guidance and crossing the stenosis/occlusion under fluoroscopy. Beam-on time and X-ray dose have been evaluated.

Results: 117 patients affected by biliary tree stenosis/occlusion not manageable with an endoscopic approach have been included in this analysis. The biliary stenosis/occlusion was malignant in 90.8% and benign in 9.2%. Technical success, considered as positioning of a drainage tube into the biliary tree, was 100%. Overall clinical success, considered as decrease in total bilirubin level after a single procedure, was 95.7%. The overall mean number of liver punctures to catheterize the biliary tree was 1.57. The mean total beam-on time was 570.4 s; the mean dose-area product was 37.25 Gy cm². No statistical significant differences were observed in terms of technical and dosimetry results according to right-sided and left-sided procedures. Complications rate recorded up to 30 days follow-up was 10.8%, all of minor grades.

Conclusions: In this series US guidance to access the biliary tree for PTBD was a safe and effective technique with an acceptable low-grade complications rate; the reported radiation dose is low.

Keywords: Biliary drainage; Complications; Percutaneous; Radiation dose; Ultrasound.

Fig. 1

a, b 63 year old man with jaundice due to hilar occlusion by a cholangiocarcinoma; venous contrast-enhanced CT scan in axial plane showing colon loops (white arrows) transposition between liver and abdominal wall, Chilaiditi syndrome. In a and in b is evident right and left lobe biliary ducts dilation (white dotted arrows), respectively. c 58 years old woman with pancreas cancer and jaundice due to distal occlusion of the choledocus causing intrahepatic biliary ducts dilation (dotted white arrows); perihepatic ascites is evident (white arrow)

Fig. 2

Same patient of Fig. 1a, b. Intercostal right lobe ultrasound scan: a colon loops interposition (white arrow) limits the access to the right-sided biliary tree. b A proper intercostal access window is individuated to avoid bowel loops and a 22-gauge spinal needle (dotted white arrow) is positioned up to the liver capsule to inject local anesthetic. c A 21 gauge Chiba needle tip (black arrow) is conducted up to the selected biliary branch. The same biliary puncture technique was adopted also for left lobe; these patients received bilateral internal PTBD due to hilar occlusion

Fig. 3

Same patient of Fig. 1c; this patient was treated 4 months before with percutaneous metallic stenting of the distal choledocus which was occluded by adenocarcinoma of pancreas head. a Venous enhanced CT scan reconstruction in coronal plane showing perihepatic ascites (black asterisk), choledocus dilation (white dotted arrow) and the occluded metallic stent (black arrow). b At the beginning of the procedure, a 5Fr pig tail catheter (white arrow) was positioned in the perihepatic space to drain the ascites; the metallic stent is evident (black arrow); this patient had also previous cardio-thoracic surgery and so metallic juncture of the sternum is evident. c After recanalization of the metallic stent (black arrow), a bilioplasty was performed; radiopaque markers of the balloon are indicated by grey arrows. d A 8.5Fr intercostal internal PTBD was positioned; small amount of hemobilia (black dotted arrow) was caused by the bilioplasty without disfunction of the drainage neither clinical effects. Extrahepatic contrast extravasation in correspondence of the point of entrance of the PTBD is also evident (black circle); this finding is common in case of patients with ascites and in small amount does not produce technical neither clinical consequences

Fig. 4

66 year old woman with duodenal carcinoma infiltrating the liver hilum. a Perihepatic ascites (white arrow) and right lobe biliary ducts dilation (white dotted arrow) are evident. b As for the patient in Fig. 3, a 5Fr pig tail catheter was positioned in the perihepatic space to drain ascites (black arrow); with the same technique described in Fig. 2, the biliary duct of the VI segment was punctured with a 21 gauge Chiba needle (black dotted arrow) with subsequent opacification of the biliary tree (grey arrow). c a 8.5Fr intercostal internal PTBD was positioned