Figure 1
PTBD
Percutaneous biliography for placement of drainage catheter.
Reintervention in percutaneous biliary drainage
SectionInterventional radiology
Case TypeClinical Cases
AuthorsLeder NI1, Grubelić Crnčević M1, Slavica M1, Kavur L1, Leder M2, Blašković D1, Popić Ramač J1, Vidjak V1
Connected authors
75 years, female
Clinical History
Elderly female patient with end-stage infiltrative gastric cancer was previously treated by percutaneous biliary drainage. The patient pulled the catheter one month after placement and was re-admitted. A bilio-cutaneous fistular canal was persistent with bile oozing on the skin surface.
Imaging Findings
A year after initial diagnosis and partial gastrectomy followed by chemotherapy and radiotherapy, CT findings show progression of the tumour mass, infiltrating distal part of the common bile duct, duodenum, pancreatic head and spreading toward the hepatic porta. Additional ultrasound study confirms dilatation of intrahepatic biliary ducts due to common bile duct obstruction by a solid mass.
ERCP stenting was attempted to relieve the patient's symptoms (jaundice) but was aborted because of distal obstruction of the common bile duct.
Finally the patient had permanent percutaneous drainage catheter placed in the common hepatic duct, after which the bilirubin levels returned to normal and the clinical symptoms of jaundice subsided (Fig. 5).
ERCP stenting was attempted to relieve the patient's symptoms (jaundice) but was aborted because of distal obstruction of the common bile duct.
Finally the patient had permanent percutaneous drainage catheter placed in the common hepatic duct, after which the bilirubin levels returned to normal and the clinical symptoms of jaundice subsided (Fig. 5).
Discussion
The patient had a partial gastrectomy, followed by chemotherapy and radiotherapy.
The patient was admitted to our hospital a year after the initial diagnosis and subsequent oncologic treatment. CT showed further progression of the tumor mass and infiltration of the surrounding structures. In cases of malignant biliary obstruction, the first course of treatment is drainage by endoscopically placed stent (ERCP stenting) [11]. However, in cases of very distal obstruction of the common bile duct, endoscopic access may often be impossible. Internal drainage by percutaneously placed stent is the second option, followed by external drainage as the preferred course of action [10, 5].
ERCP as well as percutaneous internal stenting was attempted but unsuccessful due to hard and rigid obstruction of the common bile duct. Finally, a percutaneous, external biliary drainage was performed which relieved the imminent symptoms caused by jaundice. This was a palliative procedure, but causing a significant improvement in patient's quality of life [1, 4, 8] (Fig. 1, 2).
One month after the original procedure, the patient was readmitted because she accidentally pulled the catheter. The fistular canal remained patent with bile leakage. This time we performed a twofold procedure, first inserting a new 8F catheter to ensure adequate biliary drainage. A percutaneous biliography was performed via this catheter, which also proved that the patent fistular canal was connected to the main hepatic duct. A second catheter was inserted in this canal and it was embolised with a mixture of acrylate and lipiodol (Fig. 3, 4). The embolisation procedure gave good results and the fistular canal was closed [11, 2].
While our approach and choice of materials are non-standard, this was an unusual case with a complicated, terminal patient who was admitted from an outside institution just for this procedure (no follow-up).
Percutaneous liver biliary drainage (PTBD) is a complicated procedure in interventional radiology and it is the best palliative treatment for patients with malignant obstructive jaundice where ERCP stenting is not possible [3, 7]. Acute periprocedural complications of PTBD include haemorrhage, septicaemia, AV fistula formation and subphrenic abscess formation. They are seen in 5 - 10% of cases, while minor periprocedural complications include fever and haemobilia (20 - 30% of cases). Chronic complications are experienced in almost every patient and include catheter obstruction, dislodgement, peri-catheter bile leakage and others [9, 6]. Catheters should be flushed with saline at least once a day and, exchanged every 3 - 4 months.
The patient was admitted to our hospital a year after the initial diagnosis and subsequent oncologic treatment. CT showed further progression of the tumor mass and infiltration of the surrounding structures. In cases of malignant biliary obstruction, the first course of treatment is drainage by endoscopically placed stent (ERCP stenting) [11]. However, in cases of very distal obstruction of the common bile duct, endoscopic access may often be impossible. Internal drainage by percutaneously placed stent is the second option, followed by external drainage as the preferred course of action [10, 5].
ERCP as well as percutaneous internal stenting was attempted but unsuccessful due to hard and rigid obstruction of the common bile duct. Finally, a percutaneous, external biliary drainage was performed which relieved the imminent symptoms caused by jaundice. This was a palliative procedure, but causing a significant improvement in patient's quality of life [1, 4, 8] (Fig. 1, 2).
One month after the original procedure, the patient was readmitted because she accidentally pulled the catheter. The fistular canal remained patent with bile leakage. This time we performed a twofold procedure, first inserting a new 8F catheter to ensure adequate biliary drainage. A percutaneous biliography was performed via this catheter, which also proved that the patent fistular canal was connected to the main hepatic duct. A second catheter was inserted in this canal and it was embolised with a mixture of acrylate and lipiodol (Fig. 3, 4). The embolisation procedure gave good results and the fistular canal was closed [11, 2].
While our approach and choice of materials are non-standard, this was an unusual case with a complicated, terminal patient who was admitted from an outside institution just for this procedure (no follow-up).
Percutaneous liver biliary drainage (PTBD) is a complicated procedure in interventional radiology and it is the best palliative treatment for patients with malignant obstructive jaundice where ERCP stenting is not possible [3, 7]. Acute periprocedural complications of PTBD include haemorrhage, septicaemia, AV fistula formation and subphrenic abscess formation. They are seen in 5 - 10% of cases, while minor periprocedural complications include fever and haemobilia (20 - 30% of cases). Chronic complications are experienced in almost every patient and include catheter obstruction, dislodgement, peri-catheter bile leakage and others [9, 6]. Catheters should be flushed with saline at least once a day and, exchanged every 3 - 4 months.
Differential Diagnosis List
Obstructive jaundice,Infiltrating gastric cancer
N/A
N/A
Final Diagnosis
Obstructive jaundice,Infiltrating gastric cancer
References
[1] Saad W, Darcy M (2008) Percutaneous management of biliary leaks: biliary embosclerosis and ablation. Tech Vasc Interv Radiol 11:111-9 (PMID: 18922456)
[2] Owens C, Funaki B, Ray CJ, Brown D, Gemery J, Greene F, Kinney T, Kostelic J, Lorenz J, Millward S, Nemcek AJ, Reinhart R, Rockey D, Silberzweig J, Vatakencherry G (2008) ACR Appropriateness Criteria percutaneous biliary drainage in benign and malignant biliary obstruction. ONLINE http://www.acr.org/ac
[3] Covey A, Brown K (2008) Percutaneous transhepatic biliary drainage. Tech Vasc Interv Radiol 11: 14-20 (PMID: 18725138)
[4] Abraham N, Barkun J, Barkun A (2002) Palliation of malignant biliary obstruction: a prospective trial examining impact on quality of life. Gastrointest Endosc 56:835-41 (PMID: 12447294)
[5] Ballinger A, McHugh M, Catnach S, Alstead E, Clark M (1994) Symptom relief and quality of life after stenting for malignant bile duct obstruction. Gut 35:467-70 (PMID: 7513672)
[6] Larssen L, Medhus AW, Hjermstad MJ, Körner H, Glomsaker T, Søberg T, Gleditsch D, Hovde O, Nesbakken A, Tholfsen JK, Skreden K, Hauge T (2011) Patient-reported outcomes in palliative gastrointestinal stenting: a norwegian multicenter study. Surg Endosc 25:3162-9 (PMID: 21487867)
[7] Bae J, Kim G, Ryeom H, Jang Y (2011) Percutaneous embolization of persistent biliary and enteric stulas with histoacryl. J Vasc Interv Radiol 22:879-83 (PMID: 21482136)
[8] Baijal S, Dhiman R, Gupta S, Sharma B, Roy S, Agarwal D, Choudhuri G, Saraswat V, Naik S (1997) Percutaneous transhepatic biliary drainage in the management of obstructive jaundice. Trop Gastroenterol 18:167-71 (PMID: 9612100)
[9] Kaskarelis I, Papadaki M, Papageorgiou G, Limniati M, Malliaraki N, Piperopoulos P (1999) Long-term follow-up in patients with malignant biliary obstruction after percutaneous placement of uncovered wallstent endoprostheses. Acta Radiol 40:528-33 (PMID: 10485243)
[10] Mueller P, van Sonnenberg E, Ferrucci JJ (1982) Percutaneous biliary drainage: technical and catheter-related problems in 200 procedures. AJR Am J Roentgenol 138:17-23 (PMID: 6976698)
[11] Hamlin J, Friedman M, Stein M, Bray J (1986) Percutaneous biliary drainage: complications of 118 consecutive catheterizations. Radiology 158:199-202 (PMID: 3940380)
Case information
| URL: | https://www.eurorad.org/case/10023 |
| DOI: | 10.1594/EURORAD/CASE.10023 |
| ISSN: | 1563-4086 |
Figure 2
PTBD 2
Percutaneous biliography for placement of drainage catheter.
Figure 3
Reintervention: PTBD + Embolisation
Second procedure showing percutaneous biliography for placement of second drainage catheter. The drainage catheter was placed in the right main hepatic duct through the left lobe.
Fistular canal visible with another catheter ready for embolisation.
Figure 4
Reintervention: PTBD + Embolisation 2
After successful embolisation of the fistular canal.
Liquid embolisation material was used because we were only able to place the catheter for some 5 mm into the fistular canal.
Figure 5
Early after the procedure
Visible is the placed drainage catheter, fixated to the skin. Below it the embolised canal of the previous stent. Patient is clearly still jaundiced.
PTBD
Percutaneous biliography for placement of drainage catheter.
Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Merkur, Zagreb, Croatia
Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Merkur, Zagreb, Croatia
PTBD 2
Percutaneous biliography for placement of drainage catheter.
Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Merkur, Zagreb, Croatia
Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Merkur, Zagreb, Croatia
Reintervention: PTBD + Embolisation
Second procedure showing percutaneous biliography for placement of second drainage catheter. The drainage catheter was placed in the right main hepatic duct through the left lobe.
Fistular canal visible with another catheter ready for embolisation.
Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Merkur, Zagreb, Croatia
Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Merkur, Zagreb, Croatia
Reintervention: PTBD + Embolisation 2
After successful embolisation of the fistular canal.
Liquid embolisation material was used because we were only able to place the catheter for some 5 mm into the fistular canal.
Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Merkur, Zagreb, Croatia
Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Merkur, Zagreb, Croatia
Early after the procedure
Visible is the placed drainage catheter, fixated to the skin. Below it the embolised canal of the previous stent. Patient is clearly still jaundiced.
Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Merkur, Zagreb, Croatia
Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Merkur, Zagreb, Croatia