Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Hepatobiliary Intervention


Liver Biopsy

  • Spring-powered cutting sheath biopsy devices collect more consistent core biopsies with less crush artefact than a manually operated system

  • The traditional route for liver intervention uses a horizontal right lateral intercostal approach ▸ an anterior subcostal approach (that does not traverse the pleura) is less likely to cause pulmonary complications

  • It is preferable to biopsy lesions using a route through intervening normal liver as this probably reduces the risk of haemorrhage ▸ the presence of ascites is not by itself a contraindication to biopsy

  • US is usually used as the real-time capability allows faster positioning of the needle or catheter and allows selection of an oblique approach (CT is limited to axial imaging)

  • Complications: haemorrhage ▸ pneumothorax ▸ biliary peritonitis ▸ perforation of the bowel or gallbladder ▸ haemobilia ▸ arterioportal shunt formation

Biliary System

  • MRCP and ERCP have replaced many previous roles served by biliary intervention / diagnosis

  • Mid to lower biliary obstruction is treated endoscopically in the first instance – lesions at the liver hilum are challenging to treat at ERCP and best dealt with percutaneous biliary drainage ▸ with biliary-enteric anastomoses an ERCP approach is unlikely to be possible (e.g. Roux loop or Billroth II gastric anastomosis)

Indications

Obstructive jaundice / cholangitis / evaluation and treatment of a biliary-enteric anastomosis / access for stone disease treatment/ evaluation of bile duct injuries

  • Biliary drainage often performed for patients who have failed endoscopic treatment or have altered anatomy

Technique

Supine position – right arm resting above the head ▸ conscious sedation or GA + local anaesthesia ▸ antibiotic prophylaxis ▸ lower edge of the right liver lobe is normally accessed in the mid-axillary line just above the 10 th rib, and the needle directed towards the opposite shoulder under fluoroscopic guidance ▸ stylet is removed and contrast gently injected as the needle is incrementally withdrawn ▸ bile duct access is indicated by the ‘dripping wax’ appearance (contrast dissipating into the bile ducts) ▸ biliary access on the right is preferably through an inferior duct with a straight course to the hepatic hilum (better future catheter or stent placement) ▸ proximity of left lobe ducts to the anterior abdominal wall is conducive to USS guided placement and subsequent injection under fluroscopy

  • One-stick technique: employs a small needle (e.g. 22G Chiba needle), microwire and dilator system to access the biliary tree

  • Two-stick technique: begins with biliary access and opacification using a small needle, followed by separate biliary access with a larger needle and conventional wire

Biliary drainage

A n external drain left above the level of obstruction is a temporary measure ▸ an internal – external drain (percutaneous biliary transhepatic drainage – PTBD) from the duodenum through the biliary system to the skin is preferred ▸ it can be used after biliary stenting to preserve access to the biliary tree for a few days (e.g. if there is blood in the biliary tree)

  • If a biliary stricture cannot be crossed at a first attempt, a stent can be left in situ until a repeat attempt ▸ once a stent is placed balloon dilatation can be used to bring the stent up to its nominal diameter ▸ a combined percutaneous and ERCP rendezvous approach can be considered

Complications

P ain ▸ bile leak ▸ haemobilia ▸ septicaemia

Plastic stents

These offer a lower patency rate due to encrustation of bile and often require a larger tract through the liver (10–12Fr) ▸ they are easily removed and can be used preoperatively in patients who require drainage prior to surgery

Metallic stents

These offer better patency rates than plastic stents (larger lumen reduces effects of bile encrustation) ▸ as they self expand to a predefined diameter they can be placed through smaller tracts (6-8Fr) ▸ as they elicit a marked fibrotic reaction they should not be used in benign disease or preoperatively ▸ occlusion can occur from tumour overgrowth through the stent interstices or overgrowth at the end of the stent ▸ stenting through the sphincter of Oddi may give better drainage at the risk of increased infection (enteric reflux) ▸ 10–30% will require re-intervention following blockage

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts