PERCUTANEOUS MANIPULATIONS OF THE BILIARY TRACT

Cancer of the Pancreas
PERCUTANEOUS
MANIPULATIONS OF THE
BILIARY TRACT
New Century
New Teams
New Techniques
10/09/02
CT, endoscopic US and biopsy -- adenocarcinoma of the pancreas in
pancreatic head and neck.
Extensive vascularity suggesting vascular invasion, collateral formation
and neovascularity.
The hepatic artery and PV appeared to enter the mass.
The celiac trunk was free from tumor.
The biliary and pancreatic ducts were dilated.
ERCP stent placement and sphincterotomy unable to be done
due to mass effect and vessels in area of ampulla.
No mets to the liver at this time. Pt considered inoperable.
4x3 loculated fluid collection in lesser sac, likely pseudocyst, and
large spleen.
Jaundice and pruritis worsened.
Approach for PTC?
Technique for PTC?
Catheter size?
Stent?
Immediate?
Delayed?
Uncovered?
Left approach
Easier echo
Shorter tract
More peripheral entry
Less bleeding
Stent placed
Very slow flow
Next step?
The Left Approach
Less Pain
Less Dislodgement
Easier care
Stent ?? What type??

Balloon dilation to 10 mm
Sudden give
Stent opened
What did the operator notice?
What did anesthesia notice?
What to do?
So where is the bleeding from?
Next step??
Your Rx??
Did you see the
cavernous
transformation
that showed up
on the
cholangiogram?
Acceptable?
Next step?
Patience can
sometimes be a virtue
Pt discharged day 5
BP and Hgb stable
Pruritis resolved
Total Bili 1.8
Tube capped
When should tube be removed?

Percutaneous Transhepatic
Cholangiography (PTC)
Indications
Percutaneous Transhepatic
Cholangiography (PTC)
Indications
1. Not approachable with ERCP
2. Define level of obstruction in patients with dilated bile
ducts
3. Evaluate for presence of suspected bile duct stones
4. Determine etiology of cholangitis
5. Evaluate suspected bile duct inflammatory disorders
6. Demonstrate site of bile duct leak
Dana R. Burke, et al. Quality Improvement Guidelines for
Percutaneous Transhepatic Cholangiography and Biliary Drainage JVIR.
2003, 14: 243S-246S.
Hunter 2010
GG – Hepatico-jejunostomy, elevated LFTs, stone
CBD stricture
CBD stone
Biloma mass effect
Post-Tx
Anast
Stricture
Ascites
Burke, et al
PTC
Success Rates
Threshold
(%)
Opacify dilated ducts 95
Opacify nondilated ducts 65

PTC
Major Complications
Burke, et al
Reported
rate %
Suggested
threshhold
Sepsis, cholangitis, bile leak,
hemorrhage or pneumothorax
2 4
PTCB
Indications
PTCB
Indications
1. Not approachable with ERCP
2. Decompress obstructed biliary tree
3. Dilate biliary strictures
4. Remove bile duct stones
5. Divert bile from and stent biliary leaks
Dana R. Burke, et al, Quality Improvement Guidelines for
Percutaneous Transhepatic Cholangiography and Biliary Drainage
JVIR 2003 14: 243S-246S.
Hunter 2010

GG – PSC
Progressive worsening LFTs
Candidate for liver Tx
GG – Rendezvous
For the L central duct
GG – Low CBD
Rendezvous
GG- Fail to cross
lower CBD stricture
GG – Rendezvous
R upper to
R lower
GG – R anterior
R posterior

GG – R to L
Rendevous
GG – Rendezvous and push
Both right sites to duodenum
GG – ERCP/IR
GG – 1 yr f/u MRCP
PTBD
MOST COMMON USES
• Laparoscopic duct avulsion
• Severe bacterial cholangitis
• Roux-N-Y loop
– Transplant
– Bariatric
– Whipple
• Severe lower or upper CBD stricture
– Cholangio and other carcinomas
– Sclerosing cholangitis
• Duodenal problems
– Stricture
– Diverticulum
– Edema
PTCB
Success Rates
Burke, et al
Procedural success
Cannulation
Dilated ducts 95%
Nondilated ducts 70%
Internal drainage (tube or stent) 90%
Stone removal 90%
Patency success
Stricture dilatation (benign)
Sclerosing cholangitis *
Other *
Palliative stents for malignant disease 50% @ 6m
LAPARASOPIC
COMMON BILE
DUCT INJURY
The ultimate
multi-specialty case

11/13/03 Laparoscopic cholecystectomy,
“uncomplicated”
– 24 hrs later, abdominal pain, fever, rising WBC
11/15/03 bile leak,
missed on echo
found on HIDA
11/16/03 percutaneous drainage requested
NEXT
STEP?
Try to cross the obstruction,
“pop” it open and
stent it for a VICTORY!!!
Operating physician called
“Weck” clip used to clip the
“cystic duct”
So now what?
IR/Surgery team
Clip removed
Catheter advanced - post-op drain
Bile leak stopped
Biloma drain removed
12/29/03 Re-admitted for
BRBPR and hematemesis
with a drop in hemoglobin to
6.5
Treatment???
Resuscitated, bleeding
stopped

Cross the leak
“Get distal”
Treating the Damaged
Bile Duct
Incidence of stricture
Post Weck clip ?
Post surgical repair of clip site ??
Post biloma ???
Assuming that 3-4 months of stenting would be
optimal --- How to do it ????
ERCP stents
came out one
month later
Which is why
combined procedures
Are worthwhile
Severe R side
Cath site pain
PTBD complications
0.7% to 10%
• Hemorrhage/hemobilia
• Sepsis
• Bile peritonitis (catheter dislodgement) - Right
• Persistent pain at puncture site - Right
• Pneumothorax - Right
• Pleural effusion - Right
• Pancreatitis
PTBD
Contraindications – all relative
• Platelets < 50,000
• INR prolonged
• Ascites
• Advanced metastatic disease
– Life expectancy

PTCB DOING THE ERCP THING
• Stone removal
– 212 patients
• 139 PTBD --- 73 T-tube tract
• 8-10 Fr sheath
• Dilate sphincter 10-12 mm (up to 16-18 mm)
• 11.5 mm Fogarty balloon over super-stiff wire
– Push or push plus flush
– 90.4% technical success, 93% 2nd try
• Mild pancreatitis 3/212
• Severe arterial bleed 4/212 , temp venous bleed 6/212
• Less bleeding, pancreatitis, cholangitis, and
preserved sphincter function
• Garcia L, AJR 2004; 182:663-70
PTCB FOR
CHOLANGIOCARCINOMA
• Primarily for Type 3 and 4 tumors
• ERCP success rates vary widely
– 15% (*) - 100% (**)
– Local expertise decides
– PTCB less sepsis esp c/w failed attempt at ERCP
• High quality MRCP planning
• “Primary” duct target
– Bilateral drainage has in past survived longer than unilateral (***)
• Biopsy successful in 70-90% via tract with or without a
choledochoscope (****)
• * Lefebvre JF, Dig Dis Sci, 1992
• ** Rauws EA, Eur J Surg, 2001
• *** Deviere J, Gastrointest Endosc, 1988
• *** Chou CY, Hepatogastroenterology, 1997 and 1998
Metallic Stent Placement
• Obstruction due to unresectable or
inoperable malignancy
• Postoperative tumor recurrence
• Postoperative complications
Tailored Stenting
“T, Y, X”
• Results in drainage of the entire ductal
system
• Requires bilateral access or
overlapping of stents in one duct
• No proven benefit over single side stent
– Theoretically should be improvement in
• Cholangitis
• Abcess rate
• LFT normalization

Metal Stent Outcomes
• Clinical success
– Serum bilirubin decreases 63-100%
• Quality of survival
– Solves hydration and K + loss problems
– Physiological antegrade bile flow
– Shortens hospitalization time
• Stent patency — 58 to 93% over 3 - 12 months
• Reintervention rate decreased vs plastic
• Nitinol (78%) better 6 mo patency than Z-
stents (30%) and tantalum (20%)
– (Rossi P, JVIR, 1994)
Lee KH. et al. Biliary intervention for cholangiocarcinoma.
Abdominal Imaging. 29(5):581-9, 2004 Sep-Oct.
PTFE COVERED STENTS
FOR MALIGNANT BILIARY OBSTRUCTION
• Prospective multicenter safety and efficacy
trial in Europe
• 42 pts -- 38 unilateral - 4 bilateral stents
• Technical success 100%
• 4/42 (10%) branch obstruction
• 2/42 (5%) complications
– Entry site bile leak (1) and hematoma (1)
– Only 1 mild case of lab pancreatitis (not complication)
• 8/41 (20%) 30 day mortality - none biliary
• Median primary patency 138 days
• 6/41 (15%) obstruction mean 106 days
• 3, 6,12 mo primary patency 90%, 76%, 76%
– Schoder M et al, Radiol 2002; 225:35-42
COVERED VS UNCOVERED STENTS
DOES CANCER TYPE MATTER?
• 73 patients with cancer
– Covered stents (CS) 42, Uncovered stents (US) 31
• Cholangio ca 12, gb ca 22, pancreas ca 12
– 6 mo patency CS US
• Overall 81% 50%
– Mean time of patency CS US
• Cholangio ca 15 mo 28 mo
• Gb ca 13 mo 3 mo
• Pancreas ca 12 mo 10 mo
– Kawamoto H, Hepato-gastroenterology, 2005; 52(65): 1351-6
IR Management of
Liver Transplant Complications
• Most recipients will have a complication
– Arterial
• Thrombosis 6.8% (high mortality)
• Steal 5.9%
– Portal 1.8%
– Caval

Biliary Complications of Liver Transplants
Improvements in Dilation Technique
• Possibly better with cutting balloon
– 12 pts, 49 dilations with technical success of
100%, 90% 93% for
primary, recurrent, and fail non-cutting balloon
• Saad, WEA, JVIR, 2006
• Success much less at 12 months with arterial
stenosis or occlusion
– 0% with arterial problem
– 45% with patent artery
• Saad WEA, JVIR, 2005
Late Biliary Complications of
LIVER TRANSPLANTS
• Mechanisms
– Ischemia
• 85% associated with arterial problems
– CMV infection
– Cold ischemia >12 h
• Lesions are diffuse, extensive
– Chronic repeated dilations
• Sludge, debris
– Treatment: Flushing (percutaneous) or lithotripsy
(endoscopic) or rheolytic (Loehr SP, AJR 2002)
– Risks: Infection, sepsis
Denys A, IR in the Management of Complications after Liver Transplantation
Eur Radiol (2004) 14:431
TREATING REFRACTORY
TRANSPLANT STENOSES
JS – Age 1-12
LFTs always a
little elevated
• 8 patients -- 9 stenoses
– 33 previous interventions
• Dilation 27
• Prolonged catheters 3, surgery 1, metal stent 1, atherectomy 1
– 11 home made “Z-stent” plus gortex stent-grafts with
gortex “tethers”
• 2 left in 1 pt due to clinical deterioration, patent at autopsy
• 9 planned for retrieval in 7 patients -- 8 stenoses
– 9/9 retrieved successfully -- 2 with difficulty
– 4/8 stenoses recur in 7 patients (40,90,90,90 %)
» 1/7 to surgery
» 6/7 observed, all still asymptomatic mean 12 mo later
• 5 migrate or removed 1-3 months with reocclusion in all
– Petersen B, JVIR 2000; 11:919-20
Dr J. Garcia
Says
Be a team,
Play together,
Forget yourself.
Remember,
Patients First
Or maybe,
Second
After Love
We are nothing
If we do not
Sacrifice
Some part
Of ourself
To every song
We sing