Downloaded from www.ajronline.org by 182.48.247.4 on 10/04/15 from IP address 182.48.247.4. Copyright ARRS. For personal use only; all rights reserved
309
Technical ...
.
,.
,
.
.
.
...
-
A Simple Method to Reduce Air-Bubble Artifacts Percutaneous Extraction of Biliary Stones Michael
A. Braun1
Percutaneous
lecystectomy
and Mark
extraction
;:
..
Note
....
During
B. Collins
of retained
biliary
calculi
after
cho-
is a safe and effective
technique that was first described by Burhenne in 1 973 [1]. Since then, many modifications and refinements have improved the success rate, shortened the procedure time, and minimized complications One remaining problem has been the introduction of air bubbles into the biliary system that simulate retained stones in the bile duct. These artifacts are often confusing and can lead to multiple sessions or prolonged procedure
removed. Whenever the biliary tree needs to be opacified, contrast medium is administered via the 10-mI syringe. In seven of the eight procedures we performed, all r bubbles were effectively eliminated. Any small bubbles introduced during initial opacification were trapped in the intrahepatic ducts. In one of the eight cases requiring multiple
[2-5].
times [6]. Our technique, which we have used successfully in eight cases to remove more than 1 5 stones during the past 2 years, effectively eliminates air-bubble artifacts and allows
easy and continuous
Materials
visualization
of the biliary tract.
and Methods
A guidewire is introduced into the T-tube track and placed
in an
intrahepatic
duct away from any calculi (Fig. 1). The guidewire is then exchanged for a 5-French, 50-cm Teflon catheter (Cook Corp., Bloomington, IN) with multiple side holes and a preloaded Luer-Lok adapter. The catheter is placed in a nonwedged position in an intrahepatic
bile duct
adapter and suturing patient’s
and
is secured
by tightening
the
Luer-Lok
the adapter to either the surgical drapes or
the
is then attached to a three-way stopcock. Air is bled from the catheter. A 1 0-mI syringe and a 100-mI bottle of
Conray-30
skin. The catheter
(Mallinckrodt,
St. Louis, MO) are connected
to the stop-
cock. Two additional guidewires are passed through the T-tube track into the duodenum. One is used as a safety wire and is left in place. The other is used as a working wire over which either a vascular
sheath or a stone extraction
instrument
is passed
before
the wire
Received June 11, 1991 ; accepted after revision September 3, 1991. I Both authors: Department of Radiology, A-113, Albany Medical Center
is
Fig. 1.-Diagram introduced through
February
1992 0361-803x/92/1582-0309
C American
artifacts. Catheter
Is
Hospital, 43 New Scotland Ave., Albany, NY 12208. Address reprint requests to M. B.
Collins. AJR 158:309-310,
of system to reduce air-bubble
T-tubetrack and placed securely within a blllary radical. Luer-Lok adapter Is then anchored to patient’s skin with a suture. A safety wire isintroducedinto duodenum in orderto maintain access, and a Dermis basket Is used to remove a retained stone. Billary tree can be opacifled by injection of contrast medium through a closed system.
Roentgen
Ray Society
310
BRAUN
exchanges
of baskets
remained
in the
distal
and occlusion common
balloons,
bile duct
AND
two small air bubbles
and
could
not
be eliminated.
COLLINS
AJA:i58,
find two
air bubbles
thought
were
instrument. Discussion
Downloaded from www.ajronline.org by 182.48.247.4 on 10/04/15 from IP address 182.48.247.4. Copyright ARRS. For personal use only; all rights reserved
Percutaneous
extraction
is a safe
and
effective
method
of
removing retained biliary calculi. The procedure is often complicated by artifacts simulating retained stones. Such artifacts include strands of mucus, sludge, blood clots, and air bubbles. Mucus strands and sludge are physiologic debris. Blood clots are usually the result of rigorous manipulation with extraction devices [1]. Most artifacts, however, are air bubbles. Air bubbles can be introduced into the biliary system when-
ever contrast is passed.
medium
When
an introducer
is injected
an extraction
or an extraction instrument
instrument
is passed
through
sheath, air in the sheath may be advanced
the biliary
system,
a problem
by careful
back bleeding.
that can usually
Bubbles
introduced
into
Once
should
free of all air for the remainder
remain
established,
By using this system,
the
system
of the procedure.
eliminated
all air-
bubble artifacts in five of eight cases. In two cases, very small air bubbles escaped into the intrahepatic ducts containing our
safety catheter at the onset of the procedure. These bubbles remained trapped in the ducts for the remainder of the procedure
and were of no consequence.
common
bile duct
passage
of the extraction
we did not have
that
to refill our supply
we of
contrast medium during the procedure, we saved considerable time by not having to contend with turbulent bubbles encountered during intermittent injections in an open system. An additional advantage to our system is that the intrahepatic catheter is shorter and less cumbersome than a standard safety guidewire. It is more easily and securely attached to the patient
than the standard
intrahepatic
safety
guidewire,
and the catheter is not confused with the duodenal safety wire, as often occurs. Finally, intermittent injections through our closed system reduce the total volume ofcontrast medium used, decreasing the frequency of gastrointestinal problems that have been described with continuous drip infusion systems [1].
during opacifi-
opacification
we successfully
Because
during
1992
be overcome
cation can result from either dead space in the injector syringe or air suspended within contrast medium because of turbulent filling of the syringe. To eliminate this problem, we created a closed system that can be carefully bled of all air before initial
opacification.
in the distal
introduced
February
In only one case did we
REFERENCES 1 . Burhenne HJ. Nonoperative retalned biliary tract stone extraction: a new roentgenologic technique. AJR 1973;1 17:388-399 2. Burhenne NJ. The technique of biliary duct stone extraction: experience with 126 cases. Radiology 1974;113:567-572 3. Hublity UF, Cogliano FD, Arean PJ. Early extraction of residual biliary tract stones: a two-guide-wire technique. AIR 1984;1 43:1090-1092 4. Meranze SG, Stein EJ, Burke DR, Hartz WH, McLean GK. Removal of retained common bile duct stones with angiographic occlusion balloons. AiR 1986:146:383-385 5. Kadir 5, Gadacz TA. Adjuncts and modifications to basket retained biliary calculi. Cardiovasc Radio! 1987;10:295-300 6. Burhenne HJ. Percutaneous extraction of retained biliary tract patients. AJR 1980;134:888-898
retrieval stones:
of 661
309
Technical ...
.
,.
,
.
.
.
...
-
A Simple Method to Reduce Air-Bubble Artifacts Percutaneous Extraction of Biliary Stones Michael
A. Braun1
Percutaneous
lecystectomy
and Mark
extraction
;:
..
Note
....
During
B. Collins
of retained
biliary
calculi
after
cho-
is a safe and effective
technique that was first described by Burhenne in 1 973 [1]. Since then, many modifications and refinements have improved the success rate, shortened the procedure time, and minimized complications One remaining problem has been the introduction of air bubbles into the biliary system that simulate retained stones in the bile duct. These artifacts are often confusing and can lead to multiple sessions or prolonged procedure
removed. Whenever the biliary tree needs to be opacified, contrast medium is administered via the 10-mI syringe. In seven of the eight procedures we performed, all r bubbles were effectively eliminated. Any small bubbles introduced during initial opacification were trapped in the intrahepatic ducts. In one of the eight cases requiring multiple
[2-5].
times [6]. Our technique, which we have used successfully in eight cases to remove more than 1 5 stones during the past 2 years, effectively eliminates air-bubble artifacts and allows
easy and continuous
Materials
visualization
of the biliary tract.
and Methods
A guidewire is introduced into the T-tube track and placed
in an
intrahepatic
duct away from any calculi (Fig. 1). The guidewire is then exchanged for a 5-French, 50-cm Teflon catheter (Cook Corp., Bloomington, IN) with multiple side holes and a preloaded Luer-Lok adapter. The catheter is placed in a nonwedged position in an intrahepatic
bile duct
adapter and suturing patient’s
and
is secured
by tightening
the
Luer-Lok
the adapter to either the surgical drapes or
the
is then attached to a three-way stopcock. Air is bled from the catheter. A 1 0-mI syringe and a 100-mI bottle of
Conray-30
skin. The catheter
(Mallinckrodt,
St. Louis, MO) are connected
to the stop-
cock. Two additional guidewires are passed through the T-tube track into the duodenum. One is used as a safety wire and is left in place. The other is used as a working wire over which either a vascular
sheath or a stone extraction
instrument
is passed
before
the wire
Received June 11, 1991 ; accepted after revision September 3, 1991. I Both authors: Department of Radiology, A-113, Albany Medical Center
is
Fig. 1.-Diagram introduced through
February
1992 0361-803x/92/1582-0309
C American
artifacts. Catheter
Is
Hospital, 43 New Scotland Ave., Albany, NY 12208. Address reprint requests to M. B.
Collins. AJR 158:309-310,
of system to reduce air-bubble
T-tubetrack and placed securely within a blllary radical. Luer-Lok adapter Is then anchored to patient’s skin with a suture. A safety wire isintroducedinto duodenum in orderto maintain access, and a Dermis basket Is used to remove a retained stone. Billary tree can be opacifled by injection of contrast medium through a closed system.
Roentgen
Ray Society
310
BRAUN
exchanges
of baskets
remained
in the
distal
and occlusion common
balloons,
bile duct
AND
two small air bubbles
and
could
not
be eliminated.
COLLINS
AJA:i58,
find two
air bubbles
thought
were
instrument. Discussion
Downloaded from www.ajronline.org by 182.48.247.4 on 10/04/15 from IP address 182.48.247.4. Copyright ARRS. For personal use only; all rights reserved
Percutaneous
extraction
is a safe
and
effective
method
of
removing retained biliary calculi. The procedure is often complicated by artifacts simulating retained stones. Such artifacts include strands of mucus, sludge, blood clots, and air bubbles. Mucus strands and sludge are physiologic debris. Blood clots are usually the result of rigorous manipulation with extraction devices [1]. Most artifacts, however, are air bubbles. Air bubbles can be introduced into the biliary system when-
ever contrast is passed.
medium
When
an introducer
is injected
an extraction
or an extraction instrument
instrument
is passed
through
sheath, air in the sheath may be advanced
the biliary
system,
a problem
by careful
back bleeding.
that can usually
Bubbles
introduced
into
Once
should
free of all air for the remainder
remain
established,
By using this system,
the
system
of the procedure.
eliminated
all air-
bubble artifacts in five of eight cases. In two cases, very small air bubbles escaped into the intrahepatic ducts containing our
safety catheter at the onset of the procedure. These bubbles remained trapped in the ducts for the remainder of the procedure
and were of no consequence.
common
bile duct
passage
of the extraction
we did not have
that
to refill our supply
we of
contrast medium during the procedure, we saved considerable time by not having to contend with turbulent bubbles encountered during intermittent injections in an open system. An additional advantage to our system is that the intrahepatic catheter is shorter and less cumbersome than a standard safety guidewire. It is more easily and securely attached to the patient
than the standard
intrahepatic
safety
guidewire,
and the catheter is not confused with the duodenal safety wire, as often occurs. Finally, intermittent injections through our closed system reduce the total volume ofcontrast medium used, decreasing the frequency of gastrointestinal problems that have been described with continuous drip infusion systems [1].
during opacifi-
opacification
we successfully
Because
during
1992
be overcome
cation can result from either dead space in the injector syringe or air suspended within contrast medium because of turbulent filling of the syringe. To eliminate this problem, we created a closed system that can be carefully bled of all air before initial
opacification.
in the distal
introduced
February
In only one case did we
REFERENCES 1 . Burhenne HJ. Nonoperative retalned biliary tract stone extraction: a new roentgenologic technique. AJR 1973;1 17:388-399 2. Burhenne NJ. The technique of biliary duct stone extraction: experience with 126 cases. Radiology 1974;113:567-572 3. Hublity UF, Cogliano FD, Arean PJ. Early extraction of residual biliary tract stones: a two-guide-wire technique. AIR 1984;1 43:1090-1092 4. Meranze SG, Stein EJ, Burke DR, Hartz WH, McLean GK. Removal of retained common bile duct stones with angiographic occlusion balloons. AiR 1986:146:383-385 5. Kadir 5, Gadacz TA. Adjuncts and modifications to basket retained biliary calculi. Cardiovasc Radio! 1987;10:295-300 6. Burhenne HJ. Percutaneous extraction of retained biliary tract patients. AJR 1980;134:888-898
retrieval stones:
of 661
