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:

The article makes an attempt to summarise variants of the PTBD that allows to change perceptions of this procedure as it is not a simple method as it seems in routine usage. A meaningful and reasonable use of PTBD combined with all modern technical possibilities in interventional radiology and professional personnel potential can significantly expand the scope of application for this technology and allows by using «small means» to deal with complicated clinical cases, optimizing the conditions for effective hi-tech medical support. Reducing PTBD options to the «common denominator» can optimize it's planning and accounting, can improve the quality and efficiency and can facilitate the clinical and scientific analysis of the results.

References 

1.     Remolar J., Katz S., Rybak B., et al: Percutaneous transhepatic cholangiography. Gastroenterology 1956; 31:39-46.

2.     Ivsin V.G., Jakunin A.Ju., Lukichev O.D. Chreskoghnie diagnosticheskie i ghelcheotvodjaschie vmeshatelsnva u bolnih mehanicheskoy gheltuhoy [Percutaneous diagnostic and zhelcheotvodyaschie intervention in patients with obstructive jaundice]. Tula, 2000; 312. [In Russ].

3.     Molnar W, Stockhum AE: Relief of obstructive jaundice through percutaneous transhepatic catheter - a new therapeutic method. AJR. 1974; 122: 356—367.

4.     Pereiras RV, Rheingold OJ, Huston D, et al: Relief of malignant obstructive jaundice by percutaneous insertion of a permanent prosthesis in the biliary tree. Ann. Intern. Med. 1978; 89: 589.

5.     Kukushkin A.V. Profilaktika i lechenie osloghneniy antegradnih rentgenoendobiliarnih vmeshatelstv u bolnih s mehanicheskoy gheltuhoy opuholevoy etiologii. [Prevention and treatment of complications of antegrade rentgenendobiliary interventions in patients with obstructive jaundice of tumor etiology.] Dissertacia kandidata medicinskih nauk, Moskva, 2005; 233 s. [In Russ].

6.     International classification of procedures in medicine. Volume 1 World Health Organization, Geneva, 1978.

7.     Cheng Y.E, Chen C.L., Huang T.L. Single imaging modality evaluation of living donors in liver transplantation: magnetic resonance imaging. Transplantation 2001; 15: 1527—1533.

8.     Couinaud C. Intrahepatic biliary ducts. In: Couinaud C (ed). Surgical anatomy of the liver revisited. Paris 1989; 61—74.

9.     Couinaud C. (translated by Nimura Y.) Couinaud’s surgical anatomy of the liver. Tokyo: Igaku Shoin 1996; 1.

10.   Gadzijev E.M., Ravnik D. Atlas of applied internal liver anatomy. Springer, Vienna New York Heidelberg Berlin Tokyo 1996.

11.   Healey J.E., Schroy PC. Anatomy of the biliary ducts within the human liver. Arch. Surg. 1953; 66: 599—616.

12.   Ishiyama S., Yamada Y., Narishima Y. et al. Surgical anatomy of the hilar bile duct carcinoma (in Japanese). Tan to Sui (J.Biliary Tract and Pancreas) 1999; 20: 811—829.

13.   Kawarada Y., Das B.C., Onishi H. et al. Surgical anatomy of the bile duct branches of the medial segment (B4) of the liver in relation to hilar carcinoma. J Hepatobiliary Pancreat Surg. 2000; 7: 480—485.

14.   Kawarada Y., Das B.C., Taoka H. Anatomy of the hepatic hilar area: the plate system. J. Hepatobiliary Pancreat. Surg (2000); 7: 580—586.

15.   Kida H., Uchimura M., Okamoto K. Intrahepatic architecture of bile and portal vein (inJapanese). Tan to Sui (J Biliary Tract and Pancreas) 1987; 8: 1—7.

16.   Mizumoto R., Suzuki H. Surgical anatomy of the hepatic hilum with special reference to the caudate lobe. World J. Surg. 1988; 12: 2—10.

17.   Nimura Y., Hayakawa N., Kamiya J. Clinical significance of selective cholangiography from the viewpoint of liver segment concept. Shokakibyo Gaku no Saikin no Shinpo. Tokyo 1986; 35—36.

18.   Smadja C., Blumgart L.H. The biliary tract and the anatomy of biliary exposure. In: Blumgart L.H., ed. Surgery of the liver and biliary tract; 2nd ed. Edinburgh: Churchill Livingstone 1994; 1: 11—24.

19.   Semenkov A.V., Bekbauov S.A., Eilin A.V. Anatomiya vnutripechenochnih ghelchnih protokov, variantnost stroeniya [Anatomy of the intrahepatic bile ducts, the variability of the structure]. Hirurgiya, 2009, 8, 67—72 [in russ].

20.   Wong J.H., Krippaehne W.W., Elechter W.S. Percutaneous transhepatic biliary decompression: results and complication in 30 patients. Am. J. Surg. 1984; 147: 615—617.

21.   Berquist T.H., May G.R., Johnson CM, Adson MA, Thistle J.L. Percutaneous biliary decompression: internal and external drainage in 50 patients. Am. J. Roentgenol. 1981; 136: 901—906.

22.   Clark RA, Mitehell SE, Colley DP, Alexander E: Percutaneous catheter biliary decompression. Am J. Roentgenol. 1981; 137:503—509.

23.   Eerucci J.T. Jr., Mueller PR., Harbin W.P.: Percutaneous transhepatic biliary drainage. Technique, results and applications. Radiology. 1980; 135: 1—13.

24.   Hamlin J. A., Friedman M., Stein M.G., Bray J.E: Percutaneous biliary drainage: complications of 188 consecutive catheterizations. Radiology. 1986; 158:199—202.

25.   Reimann J.E. Complications of percutaneous bile drainage. In: Classen, M., Geenen J., Kawai K.: Non surgical Biliary Drainage, Berlin: Springier. 1984; 29—35.

26.   Yee A.C.N., Ho Ch. S. Complications of percutaneous biliary drainage: benign vs. malignant diseases. AJR. 1987; 148: 1207—1209.

27.   Mueller PR., van Sonnenberg E., Eerrucci J.T. Jr.: Percutaneous biliary drainage. Technical and catheter related problems in 200 procedures. Am J. Roentgenol. 1982; 138:17—23.

28.   Passariello R., Rossi P., Simonetti G., Pavone P.: Cooperative study of percutaneous biliary drainage: statistical data on 731 patients. Radiology, in press, 1984.

29.   Bismuth H. Surgical anatomy and anatomical surgery of the liver. World J. Surg.. 1982; 6: 3—12.