Biliary Intervention

Patient Preparation

Patient preparation is similar for all transhepatic biliary interventional procedures. Antibiotic prophylaxis is mandatory before any biliary interventional procedure. Common antibiotic regimens include gentamicin 80 mg intravenously (IV) and ampicillin 1 g IV before the procedure. The author’s unit used to use this regimen but has changed to using piperacillin/tazobactam 4.5 g IV before the procedure. Piperacillin/tazobactam consists of a penicillin (piperacillin) and a β-lactamase inhibitor (tazobactam). Piperacillin is a broad-spectrum antibiotic with activity against gram-positive, gram-negative, and aerobic infections. High levels are found in bile when administered IV; and the addition of the β-lactamase inhibitor protects piperacillin against β-lactamase–producing anaerobes. Piperacillin/tazobactam is an ideal monotherapy for biliary drainage procedures, but gentamicin and ampicillin can be used when piperacillin/tazobactam is not available. For PTC, a single dose is given before the procedure. For biliary drainage, we now continue piperacillin/tazobactam 4.5 g IV t.i.d. for 2 days.

Coagulation parameters must be checked carefully and any bleeding tendency corrected with fresh frozen plasma and/or vitamin K. In jaundiced patients who are undergoing biliary drainage for relief of malignant biliary obstruction, we place the patients on intravenous fluids as soon as they are referred for biliary drainage. We use 2½ L of Hartman’s solution daily for 3-4 days around the time of the drainage procedure. Fluid replacement is important in these patients in the periprocedural time period to prevent hepatorenal failure. Many jaundiced patients have not been eating or drinking appropriately before coming to the hospital, and when they do reach hospital they are fasted for different tests, such as ERCP, computed tomography (CT) scans, and ultrasound. Usually by the time they are referred for biliary drainage they are quite dehydrated, which increases the risk of hepatorenal failure developing. Informed consent is obtained from all patients before the procedure by a member of the interventional team.

Technique

PTC is performed predominantly from the right side for diagnostic purposes. The patient is placed supine on the fluoroscopy table and the right flank is sterilely prepared. A combination of midazolam and fentanyl is used for sedoanalgesia. Under fluoroscopic control, the patient is asked to take a deep breath and the position of maximal lung descent is marked. A point is chosen one or two interspaces below this point for needle access. The needle access point should also lie in the midaxillary line. Once the point is marked on the skin, the skin is infiltrated with local anesthetic and a small incision made with a #11 scalpel blade. A 22-gauge Chiba needle (15 cm in length) is used for PTC. The needle is inserted under fluoroscopic guidance from the right flank toward the 12th vertebral body. The needle is inserted parallel to the tabletop in one smooth motion. The stylet is withdrawn and a syringe containing dilute contrast material is attached to the hub of the needle via an extension tube. The needle is slowly withdrawn and small aliquots of contrast material are injected every 1-2 mm until a bile duct is entered. When a bile duct is entered, contrast material flows away from the tip of the needle, slowly, akin to wax flowing down a candlestick. This is a characteristic phenomenon and is easily differentiated from hepatic vein or portal vein branches wherein contrast washes quickly away either toward the heart if a hepatic vein is entered or toward the periphery of the liver if a portal vein branch is entered. If a bile duct is not entered on the first pass, successive passes are made in a fan shape down through the liver toward the biliary hilum ( Fig. 20-3 ). It is important, however, not to withdraw the needle fully outside the liver capsule so that only one hole in the liver capsule is made. This helps reduce bleeding complications.

When a bile duct is entered, contrast is injected to outline the biliary system ( Fig. 20-4 ). With low bile duct obstructions, it is often advantageous to have a table that can tilt. In the supine position, the injected contrast material may not reach the level of the obstruction. By tilting the patient to a semierect position, the heavier contrast material falls and displaces the lighter bile so that the level of obstruction can be accurately depicted. Radiographs are obtained in anteroposterior (AP) and both oblique projections, and the needle is withdrawn if a biliary drainage is not planned.

Results and Complications

Success rates for PTC are between 97% and 100% in experienced hands. Technical difficulties can be experienced in patients without biliary dilatation. As many as 15-20 passes can be safely made, but thereafter, if a bile duct has not been entered, the procedure is best terminated. Alternatively, one can place a needle into the gallbladder and inject contrast material through the gallbladder to outline the biliary system. This is possible only if the biliary obstruction is below the junction of the cystic duct and common hepatic duct. Placing the patient in Trendelenburg position aids filling of the intrahepatic ducts if a gallbladder access is used.

Complications are minimal and occur in about 1%-2% of patients. Possible complications include hemorrhage, sepsis, and bile leak leading to biliary peritonitis. The incidence of hemorrhage can be decreased by correction of any abnormal coagulation parameters beforehand and by making only one hole in the liver capsule. If the blood coagulation parameters are abnormal, the percutaneous track can be embolized with Gelfoam or autologous blood clot as the needle is withdrawn though the track. This helps further decrease the incidence of hemorrhage and/or bile leak. Bile leakage is rare after PTC but occurs more frequently after biliary drainage. Appropriate antibiotic coverage can help minimize the significance of bacteremia and prevent sepsis.

Preprocedure Imaging

It is important before embarking upon a biliary drainage that all relevant information regarding the probable cause of the biliary obstruction, the level of obstruction, and details of relevant biliary anatomy are obtained. If the ERCP has failed, the endoscopists may not have injected contrast material into the biliary system. Often, even if contrast material is injected into the biliary system, it may not have outlined the whole biliary system so that bile duct anatomy cannot be ascertained. An ultrasound of the liver is important to confirm intrahepatic biliary duct dilatation, to eliminate metastatic disease, to determine the level of obstruction, and to rule out the presence of ascites. Usually an ultrasound has been performed before the ERCP; if not, it should be performed. A CT scan can also be helpful to check for evidence of a pancreatic tumor and again to look for liver metastases. More recently, in the author’s unit we have tended to perform MRC in conjunction with ultrasound in all patients referred for biliary drainage ( Fig. 20-5 ). We perform MRC using a torso coil and heavily T2-weighted fast spin echo pulse sequences. Coronal and axial acquisitions are obtained using breath-hold techniques if possible. MRC is particularly useful for evaluating biliary anatomy and planning the appropriate biliary drainage procedure in patients with hilar obstruction ( Box 20-2 ).

Right-Sided Biliary Drainage

This is the most common approach for biliary drainage. We use a one-stick needle system (Cook, Bloomington, Ind.) for biliary access ( Fig. 20-6 ). A right-sided PTC is performed as described previously. When a bile duct is entered, contrast material is injected to opacify the biliary system. If the patient is septic, the minimum amount of contrast material is injected to allow safe performance of the biliary drainage, without overdistending the biliary system. If a favorable duct is entered by the initial needle puncture, a 0.018-inch guidewire is placed through the needle and manipulated toward the hepatic hilum and common bile duct ( Fig. 20-7 ). If a favorable duct has not been entered by the initial needle, a second 22-gauge Chiba needle is used to puncture a duct with a more favorable orientation to bring the guidewire to the biliary hilum. It is important, when draining patients with hilar obstruction, to gain entry into a peripheral duct, particularly if a stent will be placed. Occasionally the 0.018-inch guidewire does not run appropriately down the duct toward the hepatic hilum. This can be remedied by turning the bevel of the needle in 90-degree aliquots and probing with the wire ( Fig. 20-8 ). Alternatively, the needle may have to be pulled back slightly if the needle is up against the medial wall of the bile duct entered. Once the 0.018-inch guidewire has gained reasonable purchase within the bile duct and is at the level of the common hepatic duct or more distally, the needle is withdrawn and the 5-French sheath assembly placed over the 0.018-inch guidewire into the bile duct.

Problems can be encountered when a vertical bile duct has been entered, in that the 5-French sheath assembly may not follow the guidewire down toward the biliary hilum. It is important to withdraw the metal stiffening cannula when the 5-French sheath assembly reaches the bile duct. The metal trocar is too stiff to follow the 0.018-inch guidewire around a 90-degree curve down into the bile duct. By withdrawing the metal trocar, the more flexible 4-French plastic cannula and 5-French sheath should follow the guidewire down toward the hepatic hilum.

Occasionally, despite appropriate technique, the plastic 5-French sheath and 4-French cannula will not follow the 0.018-inch guidewire down to the biliary hilum. In this situation, the author places the sheath assembly into the vertically orientated duct punctured, removes the 4-French plastic cannula, and places a 0.035-inch hydrophilic guidewire or 1.5-mm J-guidewire through the 5-French sheath and manipulates these down the duct. The 0.018-inch guidewire can be left in place during this maneuver because there is enough room in the 5-French sheath for both guidewires. The 5-French sheath virtually always follows the larger 0.035-inch guidewire.

Once good purchase is obtained, the 4-French inner plastic cannula and 0.018-inch guidewire are removed and a 0.035- or 0.038-inch J-guidewire placed through the 5-French sheath into the biliary tree. At this stage, the 5-French plastic sheath is removed and a hockey-stick type catheter is placed over the J-guidewire. The J-guidewire is then removed and exchanged for a 0.035-inch hydrophilic guidewire with a straight tip. The hockey-stick catheter and hydrophilic guidewire are manipulated down to a level just above the stricture. The guidewire is removed and contrast material is injected just above the stricture because often there is a small nipple of compressed duct above the stricture which points the way for guidewire manipulation. The hockey-stick catheter and hydrophilic guidewire are manipulated into the area where the nipple of contrast material was seen and the stricture probed with the hydrophilic guidewire until the stricture is crossed. The hockey-stick catheter is advanced through the stricture over the hydrophilic guidewire and both are manipulated into the proximal jejunum. The hydrophilic guidewire is exchanged for a 0.035-inch superstiff guidewire and the percutaneous track is ready for dilatation.

The percutaneous track through the liver is dilated with a 7-French dilator and a 9-French peel-away sheath placed through the percutaneous track. If the obstructing lesion is not appropriate for stenting, an internal/external biliary drainage catheter is placed to drain the biliary system. The catheter we use is an 8.3-French Ring catheter (Cook, Bloomington, Ind.) with either 32 or 42 side holes ( Fig. 20-9 ). The 32–side-hole catheter is used for patients with low CBD obstruction while the 42–side-hole catheter is used for patients with hilar obstruction. The tapered tip on the Ring catheter helps the catheter pass through the strictured area. The peel-away sheath protects the liver parenchyma, prevents buckling of the guidewire and catheter in the perihepatic space, and helps direct the pushing force applied to the catheter down the bile duct. The Ring catheter is placed well into the duodenum and the guidewire is removed. Contrast material is injected and the catheter withdrawn until contrast material is seen to opacify the biliary tree proximal to the obstruction. This implies that there are catheter side-holes above and below the level of obstruction. The catheter is placed to gravity drainage and attached to a bag.

Left-Sided Biliary Drainage

In the author’s unit we generally perform left-sided biliary drainages only when the patient has a hilar stricture. However, some authors prefer to use the left side for most, if not all, biliary drainages. A left-sided biliary drainage can be technically more challenging than using the right side, depending on the size of the left lobe, the anatomic configuration of the xiphisternum and costal margins, and the relationship of the left lobe to the costal margins and xiphisternum. There is a limited window of access to the left lobe through the inverted “V” formed by the xiphisternum and medial edges of the right and left costal margins. Depending on the size and position of the left lobe of the liver, the angle of entry into the left lobe may be shallow and within the inverted “V” formed by the bony landmarks of the upper abdomen; or indeed if the left lobe is small, it may be quite steep and angled up underneath the right costal margin ( Fig. 20-10 ).

We use ultrasound to locate the left lobe of the liver, assess the angle of approach into the bile duct, and indeed guide the needle into a bile duct. In general, the segment-3 bile duct, which courses inferiorly toward the inferior margin of the left lobe, is chosen for entry. Depending on the size of the left lobe, a segment-2 duct, which has a more horizontal course in the left lobe, can be entered if the left lobe is large enough to permit access to segment 2. The advantage of using the segment-2 duct is that there is a more gentle curve with a less acute angle for manipulating guidewires and catheters down into the common bile duct. For patients with hilar obstruction, it is important to gain access to the left lobe biliary system in as peripheral a location as the anatomy allows.

A 22-gauge Chiba needle is used to access the segment-2 or -3 duct and contrast material is injected to outline the biliary system. A 0.018-inch guidewire is manipulated toward the biliary hilum followed by the 5-French sheath system as on the right side. The hydrophilic guidewire and Kumpe catheter are used to negotiate the stricture and are placed in the proximal jejunum. The percutaneous track is dilated over a 0.035-inch superstiff guidewire and a 9-French peel-away sheath is placed. The 9-French peel-away sheath is important particularly when access is gained through a segment-3 duct because it helps direct the pushing force applied to the catheter down the common bile duct and makes placement of the catheter significantly easier. The 8.3-French Ring catheter is placed through the peel-away sheath and over the guidewire so that side holes are left above and below the stricture ( Fig. 20-11 and Box 20-3 ).

Hilar Obstruction

Patients with hilar obstruction form a subset of patients with biliary obstruction who are technically challenging to treat and who are usually best palliated by percutaneous methods if the obstruction is not surgically resectable. Knowledge of liver and biliary anatomy is important before planning biliary drainage and/or stent placement. If there is anomalous drainage of the RPD into the left hepatic duct, draining the left lobe alone may be sufficient. If not, the author’s practice is to drain both right and left lobes and stent both sides. The other significant factor that influences the approach taken is the Bismuth classification of the lesion ( Fig. 20-13 ). If there is separate occlusion of the RAD and RPD (stage 3a), then draining the right side is of little benefit to the patient. In this situation, it is often best to drain the left side by itself as long as the left lobe is of adequate size and there is no second-order bile duct involvement on the left side. When there is multisegmental involvement on both sides, there is very little that any drainage procedure can offer the patient.

Magnetic resonance cholangiography is a very useful preprocedure imaging test to assess both the anatomy of the biliary system and the Bismuth classification of the hilar tumor ( Fig. 20-14 ). Most hilar malignancies are due to cholangiocarcinoma of the bile duct or the so-called Klatskin tumor. The natural history of this tumor is to grow centrally into the liver along the bile ducts. Eventually, this leads to segmental and subsegmental obstruction. With this in mind, the principle of palliation is to drain as much functioning liver as possible. Although some operators drain one side only, we have found over the years that optimal palliation is achieved when both sides are stented. Even though our reasons for doing this are anecdotal, given the progressive nature of the disease, it seems appropriate to drain both sides. In addition, there is a faster resolution of jaundice and pruritus. Draining both sides also means that there are no undrained segments that may become infected at a later date and require a further drainage procedure. However, it is not always feasible to drain both lobes in every patient.

There are a number of metal stents used in the biliary tree, with the most popular being the Wallstent (Boston Scientific, Natick, Mass.) and the Gianturco (Cook, Bloomington, Ind.). We prefer the Wallstent, which is a self-expanding stainless steel mesh (see Fig. 20-12 ). It can have many differing lengths but the preferred length for the biliary tree is 9 cm and the preferred diameter is 1 cm. The Wallstent has a small delivery catheter (7-French), the delivery system is flexible, and the stent has a large luminal diameter (1 cm).

The Wallstent is loaded by the manufacturer on the end of the 7-French delivery catheter. The Wallstent is compressed on the end of the delivery catheter by a sheath, which is withdrawn by the operator to deliver the stent. The stent deploys from distal to proximal and tends to move a little forward as it deploys. It is important to reposition the delivery catheter during stent deployment for this reason.

Covered stents have also been used for palliation of malignant biliary obstruction (Viabil, Gore Medical, Flagstaff, Ariz.). These are best used in the lower CBD rather than the biliary hilum so that side branches are not covered.

There are a number of different approaches to stenting right and left lobes. In one approach, a single right- or left-sided biliary drainage is performed and two Wallstents are placed across the biliary hilum in a T-configuration. A stent is initially placed across the biliary hilum from right to left side to form the top of the “T” ( Fig. 20-15 ). A guidewire is placed through the metal mesh of this initial stent, down into the duodenum, and an 8-mm balloon is used to make a hole in the mesh of this stent. A second stent is placed through the hole in this initial stent to complete the “T.” We have used this approach in some patients, but have abandoned this approach because the junction of the right and left ducts are almost never horizontal and this procedure does not provide optimal drainage.

The approach that we currently use is based on bilateral deployment of Wallstents in a Y-configuration (see Fig. 20-15 ). This means that bilateral biliary drainages are performed for stent placement.

The principles of effective palliation for hilar strictures are:

• Peripheral purchase within the biliary tree

• Overstenting

Overstenting means that the proximal end of the stent is situated at least 2-3 cm above the proximal edge of the tumor. To facilitate this procedure, peripheral access into the biliary tree is mandatory when performing the initial biliary drainage.

To deploy the stents, two 0.035-inch superstiff guidewires are placed across the stricture into the duodenum. The stents are loaded on each wire in turn and placed across the stricture from right and left sides. The stents are positioned so that there is an approximate 2-3 cm of stent above the tumor. The stents are then deployed, one at a time, by simply pulling back the sheath that covers the stent on the delivery catheter ( Fig. 20-16 ).

If the procedure has gone smoothly without evidence of hemobilia, and if the patient is not septic, we generally do not leave a safety catheter. We do decompress the biliary system if not leaving a safety catheter. We also embolize the track with either Gelfoam or a mixture of glue and lipiodol. However, if there is any doubt about the patient’s condition, or if there is significant hemobilia, a safety catheter is left through both sides. An 8.3-French Ring catheter is generally used for this purpose and left for 2-3 days on gravity drainage, at which time the patient is brought back for a further cholangiogram. If at this time the biliary system is clear and the patient’s condition has normalized, the catheter is removed.

We generally do not dilate the stents in situ unless we are not leaving a safety catheter. If we are not leaving a safety catheter, then we dilate the stent in the area of the stricture with an 8-mm balloon to speed up the self-expanding process. The Wallstent is a self-expanding stent and tends to expand and shorten over time. It is an easy stent to deploy, but correct positioning is important or else the proximal end of the stent may shorten to lie within the tumor ( Box 20-4 ).