Aust. Radio]. (1 978), 22, 139
Chiba Needle Cholangiography in Hepato-Biliary Diseases M. BERRY, M.D. Assistant Professor in Radio-Diagnosis M. NARENDRANATHAN, M.D., D.M. Senior Resident in Gastro-enterology
M. RAJANI, M.D. Assistant Professor in Radio-Diagnosis SNEH BHARGAVA, M.D., M.A.M.S., D.M.R.D.(London) Professor & Head o f the Dept. of Radio-Diagnosis All India Institute of Medical Sciences, Ansari Nagar, New Delhi-NO016 (INDIA)
An aetiological diagnosis of obstructive jaundice technique in most of these patients was to estabis often a difficult clinical proposition. A battery lish the site and nature of obstruction in the of laboratory and radiological investigations at hepatobiliary system. times fails to differentiate “medical jaundice” Cholangiography was performed with a Chiba from “surgical jaundice”. Hence, continuous efforts needle according to the principles and guidelines have been made to establish new techniques t o stated by Okuda and his colleagues in 1974. investigate pa tien ts with obstructive jaundice. TECHNIQUE Percutaneous transhepatic cholangiography was first carried out b y Huard & Do-Xuan-Hop in 1937 The general principle of the technique is to using a relatively thick needle, an anterior approach introduce the needle from the flank towards an and the hit or miss method of bile aspiration. A area above the junction of the right and left number of approaches and modifications in the hepatic bile ducts and to seek a bile duct by technique have since been described. The success injecting contrast medium instead of suctioning of the technique depended on dilated biliary bile. The site of puncture is marked in the 7th passages. The more the dilatation, the higher the interspace, after measuring the thickness of the success rate and also the complications. chest. With a chest thickness of 19.5 cm or more, Ohoto & Tsuchiya from Japan in 1969 modified 12.0 cms from the table top is selected and with the technique using a long thin needle, across the a thinner chest, 11.0 crns is taken from the table entire thickness of the right lobe, injecting the top, to guide the direction of the needle. A lead contrast as the needle went in, instead of aspirat- marker is placed below the xiphisternum and the ing bile. Okuda and his associates performed this position is checked on fluoroscopy. procedure in over 300 patients with various With the patient in the supine position, the hepatobiliary diseases, both medical and surgical, site of puncture and the direction are marked on with a high degree of success and practically no the chest. Under aseptic conditions. after infiltracomplications. This technique is known as the tion with local anaesthesia and while the patient “skinny needle” or Chiba needle cholangiography. holds the breath, the Chiba needle fitted with a stylet is inserted along the marked direction toMATERIAL& METHOD wards the lead marker. The stylet is removed. the Fifty five patients with various hepatobiliary needle is connected to a syringe filled with 60% diseases were subjected t o Chiba needle Cholangio- Conray. Under image intensifier fluoroscopy graphy during the period from July I976 to control, the needle is slowly withdrawn while December 1977. The major indication for this injecting the contrast slowly but continuously. Australasian Radidogy, Vol. X X I I . No. 2. June. I978
139
M. BERRY, M. NARENDRANATHAN, M. RAJANI AND S. BHARGAVA Entry to hepatic blood vessels leads to rapid clearing of contrast, to lymphatics by slower clearing, to a biliary radicle by a branching tree pattern seen rapidly on fluoroscopy and this persists. If the first attempt fails, then the needle is reinserted 3 to 5 mm above or below the first site of puncture. The direction of the needle is always parallel to the table plane. At least five trials may be made. Once the bile duct is entered, a skiagram is taken while 1 0 to 15 ml of contrast is being injected. Then the needle is removed and further skiagrams may be taken in various positions as necessary. The final diagnosis was confirmed by operation, liver biopsy, laparoscopy or by a combination of clinical and other parameters. RESULTS Of the 55 patients who underwent the procedure, 40 were males and 15 females. Their ages ranged from 15 years to 70 years. On average, two attempts Were required to FIGURE 1 . - I . 59M - Markedly dilated intrahepatic enter a bile duct. A mean time of 4 5 minutes was biliiry channels with complete obstructionofthecommon hepatic duct at the porta hepatis. required to complete the procedure. The procedure was successful in 46 patients while unsuccessful in 7 patients. The procedure had tobediscontinued in one patient as the patient was very uncooperative and in another as he was sensitive to the contrast. These patients can be broadly classified into two groups as follows: - 49 GROUP I - Patientswith jaundice Successful Puncture in - 41 GROUP 11 - Patients with no jaundice - 6 Successful Puncture in - 5 The possible reasons for failure in 8 of the 49 patients in Group-I are summarized in Table I. TABLE I Possible reason for failure
Viral hepatitis Submassive hepatic necrosis Subcapsufar injection Sensitive to contrast Uncooperative patient
No. of Patients 2 1 3 1 1
In one of the patients of Group 11, where the technioue was a failure. multide calculi oacked in the gali bladder and common'bile duct bere seen While the rest of the biliary radicles were not dilated (seen at surgery). 140
F,GURE 2.-H.P. 42M Markedly dilated cOmmOn bile duct with a radioluscent stone at lower end, musing obstmction. Australasian Radiology. Vof. X X I I . No. 2. Jirne. I978
CHIBA NEEDLE CHOLANGIOGRAPHY IN HEPATO-BILIARY DISEASES Intrahepatic Block There were 15 patients with intrahepatic block of the bile ducts. In most of these, the block was at the junction of the right and left hepatic ducts. The intrahepatic branches showed various grades of dilatation with complete obstruction to the flow of contrast in the common hepatic duct. The block was attributed to malignant lesions. (Figure
done at the same time showed a characteristic 'E' sign of the duodenum due to pressure by a pancreatic mass in three cases of carcinoma of the head of the pancreas. In one of the patients the extrahepatic block shows rounding off of the distal end which was suggestive neither of stone nor of a mitotic lesion. This patient had a benign stricture of common 1). bile duct - congenital in nature. In three patients, there was extrinsic pressure Extrahepatic Block This was characterized on skiagrams by dilata- on the biliary passages but the flow through tion of the intrahepatic bile ducts, common hepatic common bile duct was normal. In one of these three patients, common bile duct was seen duct and common bile duct up to the site of block. compressed and displaced laterally by a smooth Extrahepatic block was seen in 20 patients - 15 soft tissue mass which later proved to be a Panof these had choledocholithiasis, single or multiple. creatic Pseudocyst. (Figure 2). The block was characterized by a deep, In two patients, multiple choledochal cysts well defined concave meniscus with acutely angled were seen with contrast flowing freely through margins. common bile duct into duodenum. Mitotic lesions in the region of the ampulla, Six of these 55 patients showed no block in pancreas, or lower end of the common bile duct appeared as a tapered distal end with smooth or the biliary tract and the bile ducts were of normal irregular margins (Figure 3). Barium meal study size (Figure 4). DISCUSSION Prior to the introduction of the fine bore Chiba needle, percutaneous t ranshepatic cholangiography
klGURE 3. -A.M. 45M - Extrahepatic obstruction at the lower end of C.B.D. which shows tapering with irregularity. Barium meal done after cholangiography shows classical E' sign in the 2nd part of duodenum. Appearances suggestive of carcinoma of the head o f the pancreas. Auslralasion Radiology. Vol. X X I I . N o . 2. June.
I Y7X
IICURE 4. -P.S. 30M - Normal sized intrahepatic biliary system, cyfti. duct and common bile duct. Gall bladder is filled r )
141
M. BERRY, M. NARENDRANATHAN, M. RAJANI AND S . BHARGAVA TABLE fV was carried out under strict surgical conditions with scheduled surgery to follow because of the ROENTGEN APPEARANCES SEEN ON PTC. frequent complications. The reported complicaRoentgen Features No. of Patient! tions include bile leakage, biliary peritonitis, intra1. Cholelithiasis 14 peritoneal haemorrhage and shock due to bloodlntrahepatic Obstruction 15 bile fistula (Koch et al 1969). There were about 11. Indicating Malignancy 10 deaths in the literature up to 1970 which were 111. Extrahepatic Obstruction 5 directly attributable to this procedure. No mortality Indicating Malignancy Pancreas, C.B.D., G.B. has so far been reported following Chiba needle
me.
IV.
Okuda ef a2 (1974) defined two merits of this technique. Firstly entry from right lateral chest wall provides a greater degree of protection from bile leakage and secondly the fine bore needle reduces the area of puncture. The present series also confirms the safety, simplicity and diagnostic value of chiba needle cholangiography. None of the patients in the present series had any serious complications. Three patients developed pain due to subcapsular injection, which responded to analgesics. One patient had bile leak and a local peritonitis developed. This settled on conservative management. The analysis of 1218 attempts collected by Seldinger from 44 publications, revealed 32 cases of biliary peritonitis, while its incidence was 0.64% in Okuda’s series. Even though our experience with
V. VI.
TABLE If Illustrates the success rates in relation to caliber of bile ducts. Percentage SUCQSSfUl Dilated bile ducts
88.6
ducts
63.6
TABLE Ill Disease groups, Number of Patients & Success rate of P.T.C. Disease Group
No. of
No. of
Malignancy (Liver, G.B., Bile Duct, Pancreas) Cholelithiasis & Choledocholithiasis Wilson’s disease Recurrent Cholangitis Recurrent Panereatitis Choledochal Cyst Haematobilia
The radiological features seen on P.T.C. are sunimarised in Table IV.
I42
VII.
Filling Defects - Clots in Biliary Passages Choledochal Cyst No Obstruction but Extrinsic Pressure on CBD. Normal Biliary Passages
1
2 3 6
this procedure is not large, the relative safety of the procedure seems to be well brought out at an incidence of 1.8%. Compared to the earlier techniques of percutaneous t ranshepat ic cho langiography , ch ib a needle cholangiography has a very much higher success rate. A seventyfour percent success rate has been achieved with conventional methods of transhepatic cholangiography, as reported earlier. Okuda reported a success rate of 93.1% while we achieved a success rate of 88.6% with the Chiba needle in dilated ducts. Subcapsular leak of the contrast was seen in three of these 44 patients and further study was discontinued. The failure in the other two patients was due to an uncooperative patient in one and sensitivity to contrast in the other. If these two cases are excluded, the success rate in the present series is 93%. The cause for failure is attributed solely to the subcapsular leak and abandoning the procedure. On the other hand, the success rate in the normal biliary tree is 63.6%. This correlated well with Okuda’s series - they reported a success rate of 67.5% in patients with none to minimal dilatation. Even if the intrahepatic ducts were not entered, the difficulty of entering the bile ducts during repeated trial runs, indicates that they are not dilated, subsequently confirmed by other data. In obstructive jaundice, the site and nature of block could be predicted accurately by this technique in 35 patients. Intrahepatic block near the porta hepatis was seen in 15 patients. This was seen either as a ‘smooth’ or ‘irregular’ taper involving either the common hepatic duct or right hepatic duct. These features suggest malignancy which was confirmed in nine patients. Exploratory laparotomy could be avoided in 5 patients, where this study showed hepatic metastasis and a high level intrahepatic obstruction. Extrahepatic obAustralasian Radiology, Vol. X X I I , No. 2, June. 1978
CHlBA NEEDLE CHOLANGIOGRAPHY IN HEPATO-BILIARY DISEASES struction at the lower end of common bile duct of haematobilia, PTC revealed multiple liner was present in. 5 patients. This was seen as an ir- filling defects in the hepatic and common bile duct regular taper or sudden cut off with rounding of suggesting blood clots. the margins o f the lower end of the common bile In three patients, there was no obstruction to duct. Barium meal examination done in three of the flow but the common bile duct was seen comthese patients revealed 'E' sign in the duodenal pressed and displaced by a pancreatic pseudocyst loop, indicating carcinoma o f head of pancreas. in one and by an enlarged gall bladder in the other This was confirmed at surgery. two. A normal biliary tree could be demonstrated The calculi in common bile duct causing com- in six patients. plete obstruction t o the flow of bile in common The incidence of bacteremia is high after chiba bile duct comprised also a major group in the needle cholangiography. This is because decompresent series, seen in 14 patients. This was charac- pression of bile ducts is difficult with this thin terised b y a smooth intraluminal radiolucency needle. When contrast isinjected into the bile duct, with convexity upwards. When the contrast went the pressure inside increases and a bile-blood around the calculus, the outline of the calculi communication is formed along the needle track could b e well made out. Associated gall bladder between a bile duct and blood vessel. This comcalculi were seen in 7 patients (Figure 5). plication is more likely in patients with complete Gall bladder filling was achieved when a delayed obstruction. To minimise the incidence of infecfilm was taken (which may reveal additional or tion, an antibiotic cover with ampicillin was given unsuspected calculi). Also, a delayed film may routinely to all patients for 2 days prior to the delineate the site and nature of obstruction more investigation. clearly because of diffusion of the contrast. An Our experience with chiba needle cholangiointerval of 2 hours has usually proved adequate graphy has been very encouraging. It gives a definite but patients require individual assessment. preoperative diagnosis and this is of great value to Two patients with multiple hepato-dochal cysts the surgeon in formulating his approach, and prowere seen in the present series. One could see the vides more time for planning of the appropriate free communication between different cysts and surgical technique. In most of these patients this the biliary tree under fluoroscopy. In one patient study was the single definitive parameter which could be relied upon. The latest addition to the established approach of the investigation of a case of jaundice has been Endoscopic retrograde cholangiography (ERC). This has been made possible because of advances in the field of fiberoptic endoscopy. Both PTC and ERC are complementary. However one could state without any doubt that Chiba needle PTC is a safe, simple technique with a high rate of success. AC KNOWLEDC EM ENT The authors wish to acknowledge their grateful thanks t o Professor B. N. Tandon, Professor & Head of the Department of Gastroenterology for his encouragement and interest in this work. We are grateful to all the members ofGastroenterology and various surgical departments for all the help they have rendered in connection with this work.
5,-C.D. 5 0 , - l n a d d i t i o n t o a radiolucent stone irregularly outlined gall bladder, with multiple stones.
at the lower end of cOmn,On bile duct, there is a
Australasian Radiology, Vol. X X I I , No. 2, June, I 9 78
SUMMARY Our experience with Chiba Needle Cholangiography in fifty five patients is presented. The technique is safe and simple. None of the patients in the oresent series had anv serious coniolications. The sdccess rate achieved with dilate4 ducts is 88.6% while with a normal hiliary system it is 63.6%.This gives a definitive preoperative diagnosis 143
M. BEKRY. M . NARENDRANATHAN, M. RAJANI AND S. BHARGAVA and is of great value to the surgeon in formulating his approach, provides more time for planning of the appropriate surgical technique and at times avoids unnecessary exploratory laparatomy.
REFERENCES I. Elks. E., Hamlyn, A. N., lain, S., Long, R. G.. S u m merfwld, J. A., Dick, R. and Shedock, S. (1976): A randomhed trial of percutaneous transbepatic cholangiogra hy with Chiba needle versus endoscopic retrograde CRokngiography for bile duct visualization in jaundice.” Gastroenterology. 71 : 439. 2. I:errucci, J. T., Wittenberg, J . . Sarno, R. A. and Dreyfuss, 1. R. ( 1976): “Fine needle transhepatic cholangiography. A new approach to obstructive jaundice.” Amer. J. Roentgenol I27 : 403. 3. trankel, M. and Gordon, R. L. (1977): “Investigation of the non-jaundiced patient by percutaneous transhepatic c~olangiography,** c/in. Rodju[. 28 : 129, 4. George, P., Young, W. B., Walker, J. G. and Sherlock,
144
S. (1965): “Value of percutaneous transhepatic cholangiographY.”Brit. J . SUW 5 2 : 779. 5 . Hmes C. H., Ferrante, W. A., Davis, W. D. Jr. and Tutton, R. A. (1972): “Percutaneous transhepatie cholangiography - experienm with 102 procedures.” Amer. J. Dig. Dis. 17 : 868. 6. Lavelle, M. I., Owen, J. P., McNulty, S. and Hamlyn, A. N. (1977): “Initial experience of percutaneous transhepatic cholangiography using a f i e gauze needle. ’ Clin. Radiul. 28 : 453. 7. Okuda, K., Tanikawa, K., Emura, T., Kuratomi, S. Jinnouchi S., Urabe, K., Sumikoshi, T., Kanda. Y.: Fukuyama, Y., Musha, H., Mori, H., Shimokawa, Y., Yakushiji, f:. and Matsuura Y. (1974): “Non-surgical percutaneous transhepatic cholangiography - Diagnostic significance in medical problems of the liver.” Amer. J. D&. Dis. 19 : 2 1. Redeker, A. G., Karvountzis, G., Richman, R. H. and Horisawa, M. (1975): “Percutaneous transhepatic cholangiography - an improved technique.” J. Amrr. mrd. Ass. 231 : 386. 9. Tabrisky, 3. and tindstrom, R. L. (1976): “Chiba percutaneous transhepatic cholangiography.” Amrr. J. Roenrgenol. 126 : 755.
Chiba Needle Cholangiography in Hepato-Biliary Diseases M. BERRY, M.D. Assistant Professor in Radio-Diagnosis M. NARENDRANATHAN, M.D., D.M. Senior Resident in Gastro-enterology
M. RAJANI, M.D. Assistant Professor in Radio-Diagnosis SNEH BHARGAVA, M.D., M.A.M.S., D.M.R.D.(London) Professor & Head o f the Dept. of Radio-Diagnosis All India Institute of Medical Sciences, Ansari Nagar, New Delhi-NO016 (INDIA)
An aetiological diagnosis of obstructive jaundice technique in most of these patients was to estabis often a difficult clinical proposition. A battery lish the site and nature of obstruction in the of laboratory and radiological investigations at hepatobiliary system. times fails to differentiate “medical jaundice” Cholangiography was performed with a Chiba from “surgical jaundice”. Hence, continuous efforts needle according to the principles and guidelines have been made to establish new techniques t o stated by Okuda and his colleagues in 1974. investigate pa tien ts with obstructive jaundice. TECHNIQUE Percutaneous transhepatic cholangiography was first carried out b y Huard & Do-Xuan-Hop in 1937 The general principle of the technique is to using a relatively thick needle, an anterior approach introduce the needle from the flank towards an and the hit or miss method of bile aspiration. A area above the junction of the right and left number of approaches and modifications in the hepatic bile ducts and to seek a bile duct by technique have since been described. The success injecting contrast medium instead of suctioning of the technique depended on dilated biliary bile. The site of puncture is marked in the 7th passages. The more the dilatation, the higher the interspace, after measuring the thickness of the success rate and also the complications. chest. With a chest thickness of 19.5 cm or more, Ohoto & Tsuchiya from Japan in 1969 modified 12.0 cms from the table top is selected and with the technique using a long thin needle, across the a thinner chest, 11.0 crns is taken from the table entire thickness of the right lobe, injecting the top, to guide the direction of the needle. A lead contrast as the needle went in, instead of aspirat- marker is placed below the xiphisternum and the ing bile. Okuda and his associates performed this position is checked on fluoroscopy. procedure in over 300 patients with various With the patient in the supine position, the hepatobiliary diseases, both medical and surgical, site of puncture and the direction are marked on with a high degree of success and practically no the chest. Under aseptic conditions. after infiltracomplications. This technique is known as the tion with local anaesthesia and while the patient “skinny needle” or Chiba needle cholangiography. holds the breath, the Chiba needle fitted with a stylet is inserted along the marked direction toMATERIAL& METHOD wards the lead marker. The stylet is removed. the Fifty five patients with various hepatobiliary needle is connected to a syringe filled with 60% diseases were subjected t o Chiba needle Cholangio- Conray. Under image intensifier fluoroscopy graphy during the period from July I976 to control, the needle is slowly withdrawn while December 1977. The major indication for this injecting the contrast slowly but continuously. Australasian Radidogy, Vol. X X I I . No. 2. June. I978
139
M. BERRY, M. NARENDRANATHAN, M. RAJANI AND S. BHARGAVA Entry to hepatic blood vessels leads to rapid clearing of contrast, to lymphatics by slower clearing, to a biliary radicle by a branching tree pattern seen rapidly on fluoroscopy and this persists. If the first attempt fails, then the needle is reinserted 3 to 5 mm above or below the first site of puncture. The direction of the needle is always parallel to the table plane. At least five trials may be made. Once the bile duct is entered, a skiagram is taken while 1 0 to 15 ml of contrast is being injected. Then the needle is removed and further skiagrams may be taken in various positions as necessary. The final diagnosis was confirmed by operation, liver biopsy, laparoscopy or by a combination of clinical and other parameters. RESULTS Of the 55 patients who underwent the procedure, 40 were males and 15 females. Their ages ranged from 15 years to 70 years. On average, two attempts Were required to FIGURE 1 . - I . 59M - Markedly dilated intrahepatic enter a bile duct. A mean time of 4 5 minutes was biliiry channels with complete obstructionofthecommon hepatic duct at the porta hepatis. required to complete the procedure. The procedure was successful in 46 patients while unsuccessful in 7 patients. The procedure had tobediscontinued in one patient as the patient was very uncooperative and in another as he was sensitive to the contrast. These patients can be broadly classified into two groups as follows: - 49 GROUP I - Patientswith jaundice Successful Puncture in - 41 GROUP 11 - Patients with no jaundice - 6 Successful Puncture in - 5 The possible reasons for failure in 8 of the 49 patients in Group-I are summarized in Table I. TABLE I Possible reason for failure
Viral hepatitis Submassive hepatic necrosis Subcapsufar injection Sensitive to contrast Uncooperative patient
No. of Patients 2 1 3 1 1
In one of the patients of Group 11, where the technioue was a failure. multide calculi oacked in the gali bladder and common'bile duct bere seen While the rest of the biliary radicles were not dilated (seen at surgery). 140
F,GURE 2.-H.P. 42M Markedly dilated cOmmOn bile duct with a radioluscent stone at lower end, musing obstmction. Australasian Radiology. Vof. X X I I . No. 2. Jirne. I978
CHIBA NEEDLE CHOLANGIOGRAPHY IN HEPATO-BILIARY DISEASES Intrahepatic Block There were 15 patients with intrahepatic block of the bile ducts. In most of these, the block was at the junction of the right and left hepatic ducts. The intrahepatic branches showed various grades of dilatation with complete obstruction to the flow of contrast in the common hepatic duct. The block was attributed to malignant lesions. (Figure
done at the same time showed a characteristic 'E' sign of the duodenum due to pressure by a pancreatic mass in three cases of carcinoma of the head of the pancreas. In one of the patients the extrahepatic block shows rounding off of the distal end which was suggestive neither of stone nor of a mitotic lesion. This patient had a benign stricture of common 1). bile duct - congenital in nature. In three patients, there was extrinsic pressure Extrahepatic Block This was characterized on skiagrams by dilata- on the biliary passages but the flow through tion of the intrahepatic bile ducts, common hepatic common bile duct was normal. In one of these three patients, common bile duct was seen duct and common bile duct up to the site of block. compressed and displaced laterally by a smooth Extrahepatic block was seen in 20 patients - 15 soft tissue mass which later proved to be a Panof these had choledocholithiasis, single or multiple. creatic Pseudocyst. (Figure 2). The block was characterized by a deep, In two patients, multiple choledochal cysts well defined concave meniscus with acutely angled were seen with contrast flowing freely through margins. common bile duct into duodenum. Mitotic lesions in the region of the ampulla, Six of these 55 patients showed no block in pancreas, or lower end of the common bile duct appeared as a tapered distal end with smooth or the biliary tract and the bile ducts were of normal irregular margins (Figure 3). Barium meal study size (Figure 4). DISCUSSION Prior to the introduction of the fine bore Chiba needle, percutaneous t ranshepatic cholangiography
klGURE 3. -A.M. 45M - Extrahepatic obstruction at the lower end of C.B.D. which shows tapering with irregularity. Barium meal done after cholangiography shows classical E' sign in the 2nd part of duodenum. Appearances suggestive of carcinoma of the head o f the pancreas. Auslralasion Radiology. Vol. X X I I . N o . 2. June.
I Y7X
IICURE 4. -P.S. 30M - Normal sized intrahepatic biliary system, cyfti. duct and common bile duct. Gall bladder is filled r )
141
M. BERRY, M. NARENDRANATHAN, M. RAJANI AND S . BHARGAVA TABLE fV was carried out under strict surgical conditions with scheduled surgery to follow because of the ROENTGEN APPEARANCES SEEN ON PTC. frequent complications. The reported complicaRoentgen Features No. of Patient! tions include bile leakage, biliary peritonitis, intra1. Cholelithiasis 14 peritoneal haemorrhage and shock due to bloodlntrahepatic Obstruction 15 bile fistula (Koch et al 1969). There were about 11. Indicating Malignancy 10 deaths in the literature up to 1970 which were 111. Extrahepatic Obstruction 5 directly attributable to this procedure. No mortality Indicating Malignancy Pancreas, C.B.D., G.B. has so far been reported following Chiba needle
me.
IV.
Okuda ef a2 (1974) defined two merits of this technique. Firstly entry from right lateral chest wall provides a greater degree of protection from bile leakage and secondly the fine bore needle reduces the area of puncture. The present series also confirms the safety, simplicity and diagnostic value of chiba needle cholangiography. None of the patients in the present series had any serious complications. Three patients developed pain due to subcapsular injection, which responded to analgesics. One patient had bile leak and a local peritonitis developed. This settled on conservative management. The analysis of 1218 attempts collected by Seldinger from 44 publications, revealed 32 cases of biliary peritonitis, while its incidence was 0.64% in Okuda’s series. Even though our experience with
V. VI.
TABLE If Illustrates the success rates in relation to caliber of bile ducts. Percentage SUCQSSfUl Dilated bile ducts
88.6
ducts
63.6
TABLE Ill Disease groups, Number of Patients & Success rate of P.T.C. Disease Group
No. of
No. of
Malignancy (Liver, G.B., Bile Duct, Pancreas) Cholelithiasis & Choledocholithiasis Wilson’s disease Recurrent Cholangitis Recurrent Panereatitis Choledochal Cyst Haematobilia
The radiological features seen on P.T.C. are sunimarised in Table IV.
I42
VII.
Filling Defects - Clots in Biliary Passages Choledochal Cyst No Obstruction but Extrinsic Pressure on CBD. Normal Biliary Passages
1
2 3 6
this procedure is not large, the relative safety of the procedure seems to be well brought out at an incidence of 1.8%. Compared to the earlier techniques of percutaneous t ranshepat ic cho langiography , ch ib a needle cholangiography has a very much higher success rate. A seventyfour percent success rate has been achieved with conventional methods of transhepatic cholangiography, as reported earlier. Okuda reported a success rate of 93.1% while we achieved a success rate of 88.6% with the Chiba needle in dilated ducts. Subcapsular leak of the contrast was seen in three of these 44 patients and further study was discontinued. The failure in the other two patients was due to an uncooperative patient in one and sensitivity to contrast in the other. If these two cases are excluded, the success rate in the present series is 93%. The cause for failure is attributed solely to the subcapsular leak and abandoning the procedure. On the other hand, the success rate in the normal biliary tree is 63.6%. This correlated well with Okuda’s series - they reported a success rate of 67.5% in patients with none to minimal dilatation. Even if the intrahepatic ducts were not entered, the difficulty of entering the bile ducts during repeated trial runs, indicates that they are not dilated, subsequently confirmed by other data. In obstructive jaundice, the site and nature of block could be predicted accurately by this technique in 35 patients. Intrahepatic block near the porta hepatis was seen in 15 patients. This was seen either as a ‘smooth’ or ‘irregular’ taper involving either the common hepatic duct or right hepatic duct. These features suggest malignancy which was confirmed in nine patients. Exploratory laparotomy could be avoided in 5 patients, where this study showed hepatic metastasis and a high level intrahepatic obstruction. Extrahepatic obAustralasian Radiology, Vol. X X I I , No. 2, June. 1978
CHlBA NEEDLE CHOLANGIOGRAPHY IN HEPATO-BILIARY DISEASES struction at the lower end of common bile duct of haematobilia, PTC revealed multiple liner was present in. 5 patients. This was seen as an ir- filling defects in the hepatic and common bile duct regular taper or sudden cut off with rounding of suggesting blood clots. the margins o f the lower end of the common bile In three patients, there was no obstruction to duct. Barium meal examination done in three of the flow but the common bile duct was seen comthese patients revealed 'E' sign in the duodenal pressed and displaced by a pancreatic pseudocyst loop, indicating carcinoma o f head of pancreas. in one and by an enlarged gall bladder in the other This was confirmed at surgery. two. A normal biliary tree could be demonstrated The calculi in common bile duct causing com- in six patients. plete obstruction t o the flow of bile in common The incidence of bacteremia is high after chiba bile duct comprised also a major group in the needle cholangiography. This is because decompresent series, seen in 14 patients. This was charac- pression of bile ducts is difficult with this thin terised b y a smooth intraluminal radiolucency needle. When contrast isinjected into the bile duct, with convexity upwards. When the contrast went the pressure inside increases and a bile-blood around the calculus, the outline of the calculi communication is formed along the needle track could b e well made out. Associated gall bladder between a bile duct and blood vessel. This comcalculi were seen in 7 patients (Figure 5). plication is more likely in patients with complete Gall bladder filling was achieved when a delayed obstruction. To minimise the incidence of infecfilm was taken (which may reveal additional or tion, an antibiotic cover with ampicillin was given unsuspected calculi). Also, a delayed film may routinely to all patients for 2 days prior to the delineate the site and nature of obstruction more investigation. clearly because of diffusion of the contrast. An Our experience with chiba needle cholangiointerval of 2 hours has usually proved adequate graphy has been very encouraging. It gives a definite but patients require individual assessment. preoperative diagnosis and this is of great value to Two patients with multiple hepato-dochal cysts the surgeon in formulating his approach, and prowere seen in the present series. One could see the vides more time for planning of the appropriate free communication between different cysts and surgical technique. In most of these patients this the biliary tree under fluoroscopy. In one patient study was the single definitive parameter which could be relied upon. The latest addition to the established approach of the investigation of a case of jaundice has been Endoscopic retrograde cholangiography (ERC). This has been made possible because of advances in the field of fiberoptic endoscopy. Both PTC and ERC are complementary. However one could state without any doubt that Chiba needle PTC is a safe, simple technique with a high rate of success. AC KNOWLEDC EM ENT The authors wish to acknowledge their grateful thanks t o Professor B. N. Tandon, Professor & Head of the Department of Gastroenterology for his encouragement and interest in this work. We are grateful to all the members ofGastroenterology and various surgical departments for all the help they have rendered in connection with this work.
5,-C.D. 5 0 , - l n a d d i t i o n t o a radiolucent stone irregularly outlined gall bladder, with multiple stones.
at the lower end of cOmn,On bile duct, there is a
Australasian Radiology, Vol. X X I I , No. 2, June, I 9 78
SUMMARY Our experience with Chiba Needle Cholangiography in fifty five patients is presented. The technique is safe and simple. None of the patients in the oresent series had anv serious coniolications. The sdccess rate achieved with dilate4 ducts is 88.6% while with a normal hiliary system it is 63.6%.This gives a definitive preoperative diagnosis 143
M. BEKRY. M . NARENDRANATHAN, M. RAJANI AND S. BHARGAVA and is of great value to the surgeon in formulating his approach, provides more time for planning of the appropriate surgical technique and at times avoids unnecessary exploratory laparatomy.
REFERENCES I. Elks. E., Hamlyn, A. N., lain, S., Long, R. G.. S u m merfwld, J. A., Dick, R. and Shedock, S. (1976): A randomhed trial of percutaneous transbepatic cholangiogra hy with Chiba needle versus endoscopic retrograde CRokngiography for bile duct visualization in jaundice.” Gastroenterology. 71 : 439. 2. I:errucci, J. T., Wittenberg, J . . Sarno, R. A. and Dreyfuss, 1. R. ( 1976): “Fine needle transhepatic cholangiography. A new approach to obstructive jaundice.” Amer. J. Roentgenol I27 : 403. 3. trankel, M. and Gordon, R. L. (1977): “Investigation of the non-jaundiced patient by percutaneous transhepatic c~olangiography,** c/in. Rodju[. 28 : 129, 4. George, P., Young, W. B., Walker, J. G. and Sherlock,
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S. (1965): “Value of percutaneous transhepatic cholangiographY.”Brit. J . SUW 5 2 : 779. 5 . Hmes C. H., Ferrante, W. A., Davis, W. D. Jr. and Tutton, R. A. (1972): “Percutaneous transhepatie cholangiography - experienm with 102 procedures.” Amer. J. Dig. Dis. 17 : 868. 6. Lavelle, M. I., Owen, J. P., McNulty, S. and Hamlyn, A. N. (1977): “Initial experience of percutaneous transhepatic cholangiography using a f i e gauze needle. ’ Clin. Radiul. 28 : 453. 7. Okuda, K., Tanikawa, K., Emura, T., Kuratomi, S. Jinnouchi S., Urabe, K., Sumikoshi, T., Kanda. Y.: Fukuyama, Y., Musha, H., Mori, H., Shimokawa, Y., Yakushiji, f:. and Matsuura Y. (1974): “Non-surgical percutaneous transhepatic cholangiography - Diagnostic significance in medical problems of the liver.” Amer. J. D&. Dis. 19 : 2 1. Redeker, A. G., Karvountzis, G., Richman, R. H. and Horisawa, M. (1975): “Percutaneous transhepatic cholangiography - an improved technique.” J. Amrr. mrd. Ass. 231 : 386. 9. Tabrisky, 3. and tindstrom, R. L. (1976): “Chiba percutaneous transhepatic cholangiography.” Amrr. J. Roenrgenol. 126 : 755.
