Percutaneous biliary drainage (PBD)
Indications
- Palliation or treatment of biliary obstruction resulting from benign (e.g., post-operative or posttransplant) or malignant strictures following failed ERCP drainage
a. Preoperative decompression prior to surgery is no longer felt to be routinely indicated; several recent evaluations of this practice and one meta-analysis have shown that it is actually associated with increased morbidity and should be avoided unless there is another compelling reason, such as cholangitis, that must be corrected before surgery (3). - Cholangitis or infected bile
- Bile duct injury or bile leak resulting from traumatic or iatrogenic causes
- Complex strictures involving both left and right ducts (e.g., Billroth IV cholangiocarcinoma, sclerosing cholangitis, and ischemic cholangitis)
- To facilitate intraductal procedures
a. Stricture biopsy
b. Brachytherapy for cholangiocarcinoma
Contraindications
Absolute
- Uncorrectable coagulopathy
- Obligatory use of Plavix
Relative
- Uncorrectable moderate coagulopathy or use of aspirin
a. Consider infusion of fresh frozen plasma (FFP), cryoprecipitate, or platelets during the procedure. - Large volume ascites
a. Consider paracentesis before and during the procedure.
b. Use a left-sided approach because ascites is frequently absent anteriorly. - Hemodynamic instability
a. Consider that it may be due to an infected bile leak that may be corrected by drainage.
Homework
Critiques?
Left duct puncture
(1) The epigastric approach avoids problems that can occur when crossing the pleural space. Entry into a peripheral portion of the duct reduces the chance of crossing a large central vessel and allows easier placement of drainage catheters.
(2) The safest target is the segment 3 duct, which is inferior and anterior to the segment 2 duct. In addition, the duct is often just slightly anterior and superior to the portal vein, which makes it a safe target
(3) Start scanning transversely and then rotate the transducer until it is parallel to the segment 2 and 3 ducts (see Fig. 52.1).
(4) The needle can then be placed into the liver in the plane of the transducer and monitored for its entire passage through the epigastric tissues and liver to the duct (Fig. 52.2). Make absolutely sure, before your needle enters the liver, that the trajectory is in the plane of the duct you wish to enter. If you are close enough, even if the needle fails to enter the duct, you will only need to pull back 1 to 2 cm to redirect the needle. The goal is to cross the liver capsule once.
(5) The needle is usually passed a few millimeters deep to the duct, and a slow, high magnification
pullback injection of contrast is performed. A mixture of 7 mL contrast to 3 mL saline is easily
seen yet not so dense to obscure repeat attempts if there is parenchymal staining.
(6) During the pullback injection, use rapid, small intermittent “puff” injections to produce a
continuous tract barely wider than the needle tip. Contrast in the portal vein or hepatic artery will
clear toward the periphery of the liver, clear rapidly and completely, and result in a parenchymal
stain in the peripheral distribution of the vessel. Contrast in a bile duct will clear centrally, clear
slowly, and not cause staining (Fig. 52.3). Contrast in a hepatic vein will clear in a cephalad and central direction, clear rapidly, and not cause staining.
(7) Overinjection of infected biliary ducts is the most common cause of sepsis during a PTC and
must be avoided. If you begin to see tiny peripheral ducts and slight sinusoidal staining when
injecting into a duct, stop immediately and reassess what you are doing and what you need to see
or accomplish.
(8) If there is an obstruction, take a specimen for culture and then advance a catheter to the
obstruction (Fig. 52.4) to make small injections and decide on therapy.
(9) If there is no obstruction, obtain images in multiple projections. Ensure that contrast clears from
the ducts and the bowel.
(10) When the cholangiographic findings are indeterminate, a pressure-flow study, a variation of the urinary Whitaker test, can be done (Chapter e-88). We often follow a simplified protocol of 10
mL per minute for 20 minutes taking pressures at baseline then every 2 minutes. Obstruction is
present if there is ductal dilatation associated with a pressure rise above 15 mm Hg (20 cm saline
if using a manometer).
Right duct - aim for seg 5
- Best to only cross the liver capsule once
- Try to numb up the liver capsule itself
Major complications (8%) with rates for individual complications ranging from 0.5% for pleural
complications to 2.5% for both sepsis and bleeding (7). In addition to the complications listed for PTC, the following complications are more specific to PBD:
- Ductal perforation with secondary bile leak, extravasation, or bleeding
- Catheter complications
a. Obstruction
(1) Debris, blood, or mucus
(2) Kinking and suture problems
b. Dislodgment - Delayed infection
a. Delayed recurrent cholangitis - Delayed bleeding
a. This is often due to a growing pseudoaneurysm, which can bleed into an adjacent duct and present as a gastrointestinal (GI) bleed.
b. Bleeding from the drainage catheter