PERCUTANEOUS MANIPULATIONS OF THE BILIARY TRACT

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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 <strong>THE</strong> 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
Page 1 and 2: Cancer of the Pancreas PERCUTANEOUS
Page 3 and 4: Percutaneous Transhepatic Cholangio
Page 5 and 6: GG - PSC Progressive worsening LFTs
Page 7: 11/13/03 Laparoscopic cholecystecto
Page 11: Biliary Complications of Liver Tran

PERCUTANEOUS MANIPULATIONS OF THE BILIARY TRACT

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