Abstract

Aim: was to assess feasibility and effectiveness of using special methods for preventing of port-biliary fistula formation, at all stages of percutaneous transhepatic cholangiostomy (PTC).

Material and methods: we analyzed results of 3786 cholangiostomies with Seldinger technique, performed during the period from 1995 to 2019. Primary puncture of target bile duct was performed with a 17,5-18G needle for Amplaz guidewire 0,035’’ with a safe J-tip. With benign lesion of the biliary tree, 2066 cholangiostomies (54.6%) were performed, with tumor – 1720 (45,4%).

Results: significant hemobilia was registered in 21 patients (0.55%) from the analyzed group (3786 PTC), while in 3 cases arteriobiliary fistula was diagnosed, in 16-portbiliary fistula, 2 - biliary-venous fistula. The frequency of portоbiliary fistulas was 0,42%. The presence of blood impurities during aspiration from bile ducts was considered as obvious sign of portоbiliary fistula. Prevention of the formation of port-biliary fistula was realized by using well-guided puncture needles of large diameter (17,5-18G), including use of the «open needle» technique and timely changing the puncture trajectory during puncture of the vessel before penetration of the bile duct. Discredited access was used only for cholangiography with simultaneous puncture of bile ducts with a second needle along a different path and control of the severity of hemobilia according to the established second conflict-free cholangiostoma. All portоbiliary fistulas were closed conservatively.

Conclusion: the use of special methods of prophylaxis, determined a low frequency of portоbiliary fistulas - 4.2 port-biliary fistulas per 1000 percutaneous transhepatic cholangiostomy (0,42%), as well as their relatively benign nature (marginal wound of lateral portal vein branches), which did not require the use of embolization techniques.

References

1.     Shiau EL, Liang HL, Lin YH. (et al.). The Complication of Hepatic Artery Injuries of 1,304 Percutaneous Transhepatic Biliary Drainage in a Single Institute. J Vasc Interv Radiol. 2017 Jul;28(7):1025-1032. doi: 10.1016/j.jvir. 2017.03.016.

2.     Dolgushin BI, Virshke ER, Cherkasov VA, Kukushkin VA, Mkrtchjan GS. Selective Embolization of Hepatic Arteries in Bleeding Complications of Percutaneous Transhepatic Biliary Dranage. Annaly khirurgicheskoy gepatologii. Annals of HPB surgery. 2007; 12(4): 63-68 [In Russ].

3.     Aung TH, Too CW, Kumar N (et al.). Severe Bleeding after Percutaneous Transhepatic Drainage of the Biliary System. Radiology. 2016 Mar; 278(3):957-8. doi: 10.1148/ radiol.2016151954.

4.     Saad WE, Wallace MJ, Wojak JC (et al.). Quality improvement guidelines for percutaneous transhepatic cholangiography, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv Radiol. 2010 Jun; 21(6): 789-95. doi: 10.1016/j.jvir.2010.01.012.

5.     Dietrich CF, Lorentzen T, Appelbaum L (et al.). EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III-abdominal treatment procedures (Long Version). Ultraschall Med. 2016 Feb;37(1):E1-E32. doi: 10.1055/s-0035-1553917.

6.     Mortimer AM, Wallis A, Planner A. Multiphase multidetector CT in the diagnosis of haemobilia: a potentially catastrophic ruptured hepatic artery aneurysm complicating the treatment of a patient with locally advanced rectal cancer. Br J Radiol. 2011, May; 84(1001):e95-8. doi: 10.1259/bjr/20779582.

7.     Quencer KB, Tadros AS, Marashi KB (et al.). Bleeding after Percutaneous Transhepatic Biliary Drainage: Incidence, Causes and Treatments. J Clin Med. 2018 May 1;7(5). pii: E94. Doi 10.3390/jcm7050094.

8.     Chanyaputhipong J, Lo RH, Tan BS, Chow PK Portobiliary fistula: successful transcatheter treatment with embolisation coils. Singapore Med J. 2014 Mar; 55(3):e34-6.

9.     Madhusudhan KS, Dash NR, Afsan A (et al.). Delayed Severe Hemobilia Due to Bilio-venous Fistula After Percutaneous Transhepatic Biliary Drainage: Treatment With Covered Stent Placement. J Clin Exp Hepatol. 2016 Sep; 6(3):241-243.

Abstract:

Aim: was to determine indications for transpapillary external-internal drainage of the biliary tree in benign diseases of the peripapillary region.

Material and methods: results of the use of externally-internally transpapillary drainage of the biliary tree from 256 patients with distal obstruction of the biliary tract were analyzed. In 154 (60,2%) cases the peripapillary obstruction was caused by tumor pathology, in 102(39,8%) cases (39.8 %) - by peripapillary benign stenotic diseases (stenosis of Vater papilla, choledocholithiasis, chronic pancreatitis, parapapillary diverticula) that have not managed to eliminate with the help of endoscopy or endoscopic benefit was initially ineffective.

Results: endoscopic papillosphincterotomy after the external-internal drainage due to syndrome of Vater papilla «acute blockage» required in 7(4,5%) patients of 154 patients with peripapillary tumor obstruction. Endoscopic papillotomy was performed in 80(78,4%) patients among 102 patients with benign distal block of common biliary duct after the external-internal drainage for same indications. In 7 cases of «acute blockage» of papilla we were forced to return to the outside cholangiostomy due to endoscopic unattainable of papilla. In summary, the syndrome of papilla «acute blockage» occurred in 87(85,3%) patients with transpapillary external- internal drainage of the biliary tree on the background of the peripapillary benign obstruction. There were no complications of papillotomy

Conclusion: the external-internal drainage of the biliary tree with the syndrome of obstructive jaundice remains an effective and pragmatic method of return of bile into the lumen of the duodenum. The most common complication of the external-internal drainage with transpapillary drainage placement is a syndrome of «acute blockage» of Vater papilla which requires endoscopic papillotomy With high frequency this syndrome occurs when forced transpapillary the external-internal drainage of the distal benign disorders of patency of the biliary tree. Minimal risk of this syndrome developing has been reported during transpapillary drainage in patients with obstructive jaundice due to peripapillary cancer.

References

1.      Jendobiliarnaja intervencionnaja onkoradiologija pod red. Dolgushina B.I. [Endobiliary interventional oncoradiology under edition of Dolgushin B.I.]. Moscow. 2004: 224 [In Russ].

2.      Intervencionnaja radiologija v onkologii (puti razvitija i tehnologii): Nauchno-prakticheskoe izdanie. Gl. red.: Granov A.M. i Davydov M.I.; red.: Tarazov P.G. i Granov D.A. 2- e izd., dop [Interventional radiology in oncology (the path of development and technology): Scientific-practical publication. hl. еd.: Granov A.M. and Davydov MI; еd .: Tarazov P.G. and Granov D.A. 2nd ed, dop.]. St. Petersburg. 2013: 560 [In Russ].

3.      Qian X.J., Zhai R.Y, Dai D.K, et al. Treatment of malignant biliary obstruction by combined percutaneous transhepatic biliary drainage with local tumor treatment. World J Gastroenterol. 2006; 12(2):331-5.

4.      Luchevaja diagnostika i maloinvazivnoe lechenie mehanicheskoj zheltuhi. Rukovodstvo pod red. Kokova L.S., Chernoj N.R., Kuleznevoj Ju.V. [Radiological diagnosis and minimally invasive treatment of obstructive jaundice. Guide. Under edition of Kokov L.S., Chernaya N.R., Kulezneva Ju.V.]. Moscow. 2010: 288 [In Russ].

5.      Jo J.H., Park B.H. Suprapapillary versus transpapillary stent placement for malignant biliary obstruction: which is better? J Vasc Interv Radiol. 2015; 26(4):573-582.

6.      Lee D.H., Yu J.S., Hwang J.C., Kim K.H. Percutaneous placement of self-expandable metallic biliary stents in malignant extrahepatic strictures: indications of transpapillary and suprapapillary methods. Korean J Radiol. 2000;1(2):65-72.

Abstract:

The importance of using minimally invasive techniques in management of pancreatic pseudocysts is evident today. In order to evaluate the efficacy of puncture-draining interventions, analysed herein are therapeutic outcomes in 102 patients. The patients were subdivided depending on the causes of pathology, localization, forms and presence of complications. Diagnosis included an ultrasonographic study. Suspected for neoplastic cysts, 21 patients underwent computed tomography, 42 - duodenoscopy, 17 - endoscopic retrograde pancreatocholangiography. Taking into consideration a high risk of pancreatic fistulas formation, after external drainage, we isolated a high-risk group comprising 36 people, and a group of 66 subjects with no risk of this complication. The latter underwent ultrasonography-controlled external drainage. Of these, 49 patients were subjected to drainage by the Seldinger technique, 12 - large-calibre percutaneous external drainage. Complications were observed in 3 subjects. Patients at risk of a complication underwent ultrasonographically and endoscopically controlled internal drainage. Complications were noted in 4 cases. Of these, two, during transduodenal drainage, developed bed-sores of the superior mesenteric artery branches, and one patient developed abdominal haemorrhage. In this connection we refused carrying out transduodenal drainage. The long-term results in patients with cystoduodenal stents were followed-up in 19 subjects. By month six, the stent detached spontaneously in 6 patients, being removed endoscopically in 8 subjects. Fifteen patients with intrapancreatic hypertension were subjected to endoscopic papillosphincterotomy. The duration of the hospital stay amounted to 23-28 days. Hence, internal drainage of pancreatic pseudocysts, followed by cystoduodenal stenting in patients at risk of an external pancreatic fistula within the described therapeutic-and-diagnostic algorithm is an operation of choice.

References

1.     Багненко С.Ф., Гольцов В.Р. Лечение острого панкреатита в ферментативную фазу заболевания. Вестник хирургии им. И.И. Грекова. 2006; 165 (1): 117.

2.     Акилов Х.А., Ваккасов М.Х. Лечебная тактика при поздних осложнениях панкреонекроза. Материалы 9 Всероссийского съезда хирургов. Волгоград. 2000; 7.

3.     Кадощук, Т.А., Кадощук Ю.Т., Бондарчук О.И. Диагностика и лечение кист поджелудочной железы. Анналы хирург. гепатологии. 1999; 4 (2): 159-160.

4.     Погребняков В.Ю. Малоинвазивное хирургическое лечение ложных кист поджелудочной железы, связанных с панкреатическими протоками. Анналы хирург. гепатологии. Материалы 5-й конф. хирургов - гепатологов. Томск. 1997; 2: 114.

5.     Kloppe G. Pseudocysts and other non-neoplastic cysts of the pancreas. Semin. Diagn. Pathol. 2000; 17 (1): 7-15.

6.     Багненко С.Ф., Курыгин Ф.Ф., Рухляда Н.В., Смирнов А.Д. Хронический панкреатит. Руководство для врачей. СПб.: Питер. 2000; 416.

7.     Данилов М.В., Федоров В.Д. Хирургия поджелудочной железы. М.: Медицина, 1995; 512.

8.     Froschle G., Doris H., Kremer B. et al. Pancreas-pseudozysten und hire interdiszinare therapy. Zbl. Chir. 1991; 116.359-368.

9.     Дадвани С.А., Лотов А.Н., Мусаев Г.Х., Заводнов В.Я. Отдаленные результаты цистогастро- и цистодуоденостомий под ультразвуковым и эндоскопическим контролем в лечении псевдокист поджелудочной железы. Анналы хирургической гепатологии. 1999; 4 (2): 153.

10.   Мишин, В.Ю., Квезерова А.П. Современный подход к лечению псевдокист поджелудочной железы. Анналы хирургии. 2000; 3: 32-39.

11.   Русин В.И., Болдижар А.А. Эндоскопические способы лечения псевдокист поджелудочной железы. Материалы X юбилейного конгресса по эндоскопической хирургии. 2006; 185.

Abstract:

Aim: was to estimate the expediency of one-time sanation of the gallbladder, performed under ultrasound control in patients with acute cholecystitis as a preoperative preparation.

Material and methods. For the period 2007-2016, 1365 sanations of the gallbladder were performed in 1289 patients with acute cholecystitis. In 1284 cases (94.1%), the manipulation was single-staged, performed under local anesthesia by echo-puncture needles, caliber of 17.5 G under ultrasound control by the "free hand" method or using a program of biopsy cursor, percutaneously transhepatic. Access was made through the hepatic parenchyma with a thickness of at least 10 mm. Results. Sanation of the gallbladder was effective in all 1365 cases. Repeated sanitation in a day was necessary in 76 patients. Cholecystectomy within the current hospitalization was performed ir 1132 of (87.8%) 1289 patients, in terms from 1 to 4 days after initial manipulation. The dislocation of the blocking gall-stone from the cervical region of the gallbladder into its lumen was made with a rigid 0.035" gidewire in order to restore cystic duct flow was effective in 122 cases (35.2%). Complications: subcapsular hematomas of the liver in the puncture zone - 4 (0.3%), bilomus of the gallbladder bed - 1 (0.07%), bleeding to the gallbladder lumen - 11 (0.8%) were treated conservatively. There were no lethal outcomes.

Conclusion: one-time sanation of gallbladder allows to decompress safely the gallbladder, to stop pain syndrome, to conduct a full pre-examination and preoperative preparation of patient and perform cholecystectomy in the most comfortable and safe conditions in a delayed or planned order. 

References

1.     Buyanov V.M., Ishutinov V.D., Zinyakova M.V., Titkova I.M. Ultrazvukovaya klassifikatsia ostrogo holetsistita. [Ultrasound classification of acute cholecystitis.] Vserossijskaja konferencija hirurgov: Tezisy dokladov. [Proc. Conf. Surgeons: All-Russian conference of surgeons: Tez. dokl]. Yessentuki. 1994; 51-52 [In Russ].

2.     Takada T., Strasberg S.M., Solomkin J.S., Pitt H.A., Gomi H., Yoshida M., Mayumi T., Miura F., Gouma D.J., Garden O.J., Bьchler M.W., Kiriyama S., Yokoe M., Kimura Y, Tsuyuguchi T., Itoi T., Gabata T., Higuchi R., Okamoto K., Hata J., Murata A., Kusachi S., Windsor J.A., Supe A.N., Lee S., Chen X.P., Yamashita Y, Hirata K., Inui K., Sumiyama Y Tokyo Guidelines Revision Committee. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013; 20(1): 1 -7. doi: 10.1007/s00534-012-0566-y. PMID: 23307006.

3.     Yokoe M., Takada T., Strasberg S.M., Solomkin J.S., Mayumi T., Gomi H., Pitt H.A., Garden O.J., Kiriyama S., Hata J., Gabata T., Yoshida M., Miura F., Okamoto K., Tsuyuguchi T., Itoi T., Yamashita Y, Dervenis C., Chan A.C., Lau W.Y, Supe A.N., Belli G., Hilvano S.C., Liau K.H., Kim M.H., Kim S.W., Ker C.G. Tokyo Guidelines Revision Committee. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2013; 20(1):35-46. doi: 10.1007/s00534-012-0568-9. PMID: 23340953.

4.     Kimura Y, Takada T., Strasberg S.M., Pitt H.A., Gouma D.J., Garden O.J., Bьchler M.W., Windsor J.A., Mayumi T., Yoshida M., Miura F., Higuchi R., Gabata T., Hata J., Gomi H., Dervenis C., Lau W.Y, Belli G., Kim M.H., Hilvano S.C., Yamashita Y TG13 current terminology, etiology, and epidemiology of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013; 20( 1 ):8-23. doi: 10.1007/s00534-012-0564-0. PMID: 23307004.

5.     Mayumi T., Someya K., Ootubo H., Takama T., Kido T., Kamezaki F., Yoshida M., Takada T. Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis. J UOEH. 2013; 35(4):249-57. PMID: 24334691.

6.     Briskin B.S., Minasyan A.M., Vasilieva М.А., Barsukov M.G. Chreskozhnaja chrespechenochnaja mikroholecistostomija v lechenii ostrogo holecistita. [Percutaneous transhepatic microcholecystostomy in acute cholecystitis treatment]. Annaly khirurgicheskoy gepatologii. 1996; 1(1):98-107 [In Russ].

7.     Ivanov S. V., Okhotnikov O.

Abstract:

We have retrospectively analyzed results of 100 patients’ interventional radiology methods in cases of difficulties during endoscopy choledocholithiasis treatment. It was determined that transcutaneous transhepatic cholangiostomy is a universal method of biliary decompression in case of dilatation of intrahepatic bile ducts, and can be the first stage of treatment in patients with choledocholithiasis which may be transformed consistently in endoscopic interventions, or – in case of its inefficiency or inexpediency may be transformed into percutaneous choledocholithotripsy and lithoextraction. The number of choledocholithotripsy and lithoextraction varied from 1 to 3 interference. Adequacy of lithoextraction from common bile duct was controlled by the repeated direct cholangioscopy and was confirmed by antegrade cholangiography. Complications of transhepatic method of choledocholithotripsy and lithoextraction included bacterial shock (6%), insignificant hemobilia (8%), migration (4%) and dislocation of cholangiostomy with disturbance of its drainage function (7%). Complications were eliminated successfully and didn’t change treatment tactic. There were no fatal outcomes in investigated group of patients. Antegrade percutaneous choledocholithotripsy and lithoextraction is the method of choice in case of impossibility of transpapillary endoscopical or traditional surgical treatment of choledoholithiasis.

References

1.     Нестеренко Ю.А., Лаптев В.В., Цкаев А.Ю. и др. Актуальные вопросы диагностики и лечения больных микрохоледохолитиазом. Анналы хирургической гепатологии. 2007; 12 (2): 62–68.

2.     Котовский А.Е., Глебов К.Г. Эндоскопическое транспапиллярное стентирование желчных протоков. Анналы хирургической гепатологии. 2008; 13 (1): 66–71.

3.     Шевченко Ю.Л., Ветшев П.С., Стойко Ю.М. и др. Диагностика и хирургическая тактика при синдроме механической желтухи. Анналы хирургической гепатологии. 2008; 13 (4): 96–105.

4.     Балалыкин А.С., Балалыкин В.Д., Гвоздик В.В. и др. Дискуссионные вопросы хирургических вмешательств на большом сосочке двенадцатиперстной кишки. Анналы хирургической гепатологии. 2007; 12 (4):45–50.

5.     Гальперин Э.И., Ветшев П.С. Руководство по хирургии желчных путей. М.: Издательский дом Видар-М. 2006; 568.

6.     Шулутко А.М. Хирургическое лечение желчнокаменной болезни. 50 лекций по хирургии. М.: Медиа Медика. 2003; 198–206.

7.     Истомин Н.П., Султанов С.А., Архипов А.А. Двухэтапная тактика лечения желчнокаменной болезни, осложненной холедохолитиазом. Хирургия. 2005; 1: 48–50.

8.     Chen C. et al. Reappraisal of percutaneous transhepatic cholangioscopic lithotomy for primary hepatolithiasis. Surg. Endosc. 2005; 19 (4): 505–509.

9.     Ell C. et al. Laser lithotripsy of difficult bile duct stones by means of a rhodamine-6G laser and integrated automatic stone-tissue detection system. Gastrointest Endosc. 1993; 39: 755–762.

10.   Nadler R.B. et al. Percutaneous hepatolithotomy. Тhe the Northwestern University experience. Endourol. 2002; 16: 293–297.

11.   Ogawa K. et al. Percutaneous trashepatic small-caliber choledochoscopic lithotomy. А safe and effective technique for percutaneous transhepatic common bile duct exploration in high-risk eldery patients. Hepatobiliary Pancreat Surg. 2002; 9 (2): 213–217.

12.   Долгушин Б.И., Патютко Ю.И., Нечипай А.М. и др. Антеградные эндобилиарные вмешательства в онкологии. Причины, профилактика и лечение осложнений. М.: Практическая медицина. 2005; 176.

Abstract:

We have retrospectively analyzed results of 12 patients underwent radiological interventions for scarring strictures correction of biliodigestive anastomoses after reconstructive surgery due to iatrogenic damage of extra hepatic biliary ducts. It was determined that ultrasonography is the main technique of biliary hypertension diagnostics. Antegrade cholangiography gives an ability to determine the level and type of extrahepatic biliary ducts strictures. Adequate biliary decompression was achieved by transcutaneous transhepatic drainage of biliary tree with insertion of cholangiostomical drainage near the biliodigestive anastomoses. Antegrade recanalization technique and dilatation of biliodigestive anastomosis strictures was used for dilatation of scarring stricture. Balloon plastic of anastomoses was ended with forming of external-internal draining for 9-12 months with step-by-step balloon dilatations every 3 months. Stenting of biliodigestive anastomosis' strictures was made in 4 cases Postoperative period without relapses after radiological interventions lasts from 2 till 7 years of observing.

References 

1.    Хотиняну В.Ф., Фердохлеб А.Г., Хотиняну А.В. Хирургическое лечение больных со стриктурами внепеченочных желчных протоков. Анналы хирургической гепатологии. 2008; 13 (1): 61-65.

2.    Гальперин Э.И. Что должен делать хирург при повреждении желчных протоков? 50 лекций по хирургии. М.: Медиа Медика. 2003; 198-206.

3.    3. Гальперин Э.И., Чевокин А.Ю. Факторы, определяющие выбор операции при «свежих» повреждениях магистральных желчных протоков. Анналы хирургической гепатологии. 2009; 14 (1): 49-56.

4.    Руководство по хирургии желчных путей. Под ред. Э.И. Гальперина, П.С. Ветшева. М.: Издательский дом Видар-М. 2006; 568.

5.    Murr M.M. et al. Of biliary reconstruction after laparoscopic bile duct injuries. Arch. Surg. 1999; 134 (6): 604-610.

6.    Schmidt S.C. et al. Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy. Br. J.Surg. 2005; 92 (1): 76-82.

7.    McPherson S.J. et al. Percutaneous transjejunal biliary intervention. 10-year experience with access via Roux-en-Y loops. Radiology. 1998; 206: 665-672.

8.    Quintero G.A., Patino J.F. Surgical management of benign strictures of biliary tract.

9.    World. J. Surg. 2001; 25: 1245-1250. Корымасов Е.А., Богданов В.Е., Романов В.Е. и др. Эффективность эндобилиарных вмешательств при стриктурах протоков и анастомозов. Анналы хирургической гепатологии. 2008; 13 (3): 123-124.

10.  Хальзов А.В., Анищенко В.В., Штофин С.Г. Применение нитиноловых стентов для лечения посттравматических рубцовых стриктур внепеченочных желчных протоков. Анналы хирургической гепатологии. 2008; 13 (3): 144.

11.  Bismuth N., Majno P.E. Вiliary strictures. Classification based on the principle of surgical treatment.  World. J. Surg. 2001; 25  (10): 1241-1244.