Clinical Aspects of Nonsurgical Percutaneous Transhepatic Bile Drainage in Obstructive Lesions of the Extrahepatic Bile Ducts JAN ANDERS HANSSON, M.D.,* JURGEN HOEVELS, M.D., GORAN SIMERT, M.D.,* ULF TYLEN, M.D., JOHANNES VANG, M.D.* Percutaneous transhepatic cholangiography (PIC) with subsequent external bile drainage by nonsurgically established percutaneous transhepatic intubation of bile ducts was performed in 105 patients with obstructive jaundice. Recovery of liver function and improvement in the patients' general condition prior to radical or palliative surgery, nonsurgical palliation in advanced cases of malignancy as well as relief of postoperative leakage from a biliodigestive anastomosis are the indications for the bile drainage technique used in the present study. Clinical aspects such as optimal period of preoperative drainage, frequency of catheter dislodgement, and rate of complications such as cholangitis, bile leakage to the abdominal cavity and risk for peritoneal hemorrhage are discussed. Two deaths occurred within this series.
From the Departments of Surgery and Diagnostic Radiology, University Hospital, Lund, Sweden
Methods The patient is premedicated with 10 mg Valium® and 0.5 mg Atropin intramuscularly. By fluoroscopy the approximate position of the hilum of the liver is located and at the corresponding level local anesthesia is given in the skin and the intercostal muscles in the right midaxillary line. From this point the procedure is started with a puncture towards the hilum of the liver with a fine needle (OD 0.9 mm, length 15 cm) parallel to the table top and directed towards the estimated position of the liver hilum. As the needle is withdrawn, contrast medium is cautiously injected during fluoroscopy. When filling of nondilated bile ducts is obtained and passage of contrast medium to the duodenum is demonstrated, the procedure is terminated. If dilated bile ducts are filled, the needle is withdrawn and the procedure is continued with a puncture from the same point towards a dilated bile duct with a 27 cm needle sheathed with a polyethylene fluoroscopy with horizontal and vertical beam direction is of great help, since the needle tip can then be placed exactly in a peripheral bile duct. When there is access to single beam fluoroscopy alone the puncture needle is immediately withdrawn and the catheter is gradually retracted until bile drips. A guide wire with a slightly bent soft tip is then advanced through the catheter into the bile duct and manipulated as close as possible to the site of the obstruction. The catheter is pushed over the guide wire, after the removal of which the biliary tree is filled and films are exposed for diagnostic purposes. After demonstration of the site and appearance of the obstruction, the puncture catheter is exchanged for a polyethylene catheter (OD/ID 2.2/1.4 mm) with multiple side-holes close to the tip. The drainage catheter is attached to the skin by sutures and connected to a bag for collection of the drained bile.
pERCUTANEOUS TRANSHEPATIC ACCESS to the biliary
system has provided a satisfactory solution to the problems of palliative bile drainage in unresectable tumors of the extrahepatic bile ducts and the periampullary region.3 4'6'12'20 Via the same route, temporary decompression and bile drainage can be achieved prior to radical operation. 2-4,6-11,13,14,20 In a previous report the technique and complications involved in percutaneous transhepatic cholangiography (PTC) with and without external drainage were reported.20 The present investigation consists of an extended series of patients. The purpose has been to delineate the problems and the advantages in using this drainage procedure.
Subjects The series comprises 105 patients, 60 men and 45 women ranging from 34 to 84 years of age (mean = 50) who had obstructive jaundice and drainage carried out by percutaneous transhepatic technique. A summary of the final diagnosis verified either by operation or postmortem examinations appears in Table 1. * Present address: Department of Surgery, Eksjo-Nassjo Hospital, Eksjo, Sweden. Reprint requests: Jurgen Hoevels, M.D., Department of Diagnostic Radiology, University Hospital. S-221 85 Lund, Sweden. Submitted for publication: June 2, 1978.
0003-4932/79/0100/0058 $01.15 © J. B. Lippincott Company
58
PERCUTANEOUS TRANSHEPATIC BILE DRAINAGE
Vol. 189oNo. I
Results
TABLE 1. Diagnosis in 105 Patients Treated with Nonsurgical Percutaneous Transhepatic Intlubation of the Biliary System
Drainage Time
Group 1. The percutaneous drainage period was followed by operation and biliodigestive anastomosis in 68 patients. The drainage time varied from one day to 150 days (median 15 days) while half of the patients were operated upon within the interval 7-28 days. Group 2. The external bile drainage in 32 patients was not followed by operation with biliodigestive anastomosis. Operation was originally planned in eight of these patients but their condition deteriorated rapidly despite adequate drainage and they died without surgery. Drainage time among the latter eight patients was 2-35 days (median 14 days). The remaining patients in the group had transhepatic drainage as a final palliative procedure. Drainage time among these patients varied from one week to 19 months (median two months) while half of the patients were drained for one to four months. Group 3. This small group comprises five patients in whom the external drainage was arranged as a temporary relief in the postoperative period because of leaking biliodigestive anastomosis. Time of drainage varied from one to eight weeks. Decrease of jaundice. All the patients had varying degrees ofjaundice at the time of PTC. The mean value of bilirubin in serum in the patients in group 1 was 14.8 mg/100 ml before drainage. At the time of operation the mean bilirubin in these patients was reduced to 7.7 mg/100 ml. The mean lowest bilirubin levels during drainage in the patients in group 2 was 6 mg/100 ml. To further analyse the relation between drainage time and the effect of drainage on the level of bilirubin, patients without evidence of liver disease other than that caused by the extrahepatic bile obstruction were selected. In 25 patients (21 from group 1 and four from 2) adequate drainage was established for at least two weeks and during this period several determinations of the bilirubin level were carried out. The results appear in Figure 1. The mean level of serum bilirubin was initially 17 mg/100 ml and after two weeks of drainage it had declined to 5 mg/100 ml. The serum bilirubin concentration could be followed for four weeks in 11 patients and decreased during that period to less than 3 mg/100 ml. The average volume of drained bile in the 25 patients was 610 ml124 hours (range 260-1,220 ml). The drained volume as a rule was the same at the beginning of the period as after two weeks of drainage. There was no correlation between the volume of drained bile and the decrease in bilirubin. The volume of drained bile in a group of 13 patients with liver metastases was also studied. The mean initial value of bilirubin in this latter group was 17 mg/100 ml. After two weeks
59
Diagnosis
Number of Cases
Periampullary carcinoma Carcinoma of the proximal part of the extrahepatic bile ducts and gallbladder Malignant tumor of the liver. Metastases to hepatoduodenal ligament latrogenic strictures of the bile duct Choledocholithiasis Cirrhosis Chronic pancreatitis
49
Total
105
24 12 10 6 3 I
ofdrainage the level was 9 mg/I00 ml. The mean volume of drained bile was 360 ml/24 hours (range 160-625 ml). During the first week of drainage bilirubin decreased rapidly. Decline is less marked after about two weeks. The degree ofjaundice at the time of PTC seems to be of minor importance since patients with high initial bilirubin levels reached approximately the same level after two weeks of drainage as those patients who initially had the lowest levels of bilirubin (Fig. 1). Catheter problems delayed the decrease in bilirubin in 11 patients in group 1. Catheter displacement necessitated reposition of the catheter in five patients, in two of these on two occasions. In the remaining cases the holes in the catheter were obstructed by detritus. The bile flow could be re-established by flushing the catheter. mg/dl 25
20
15
10
0
Time. days
FIG. 1. Total serum bilirubin concentration during drainage period of 14 days in a group of 25 patients with satisfactory drainage function and healthy liver (i.e. without metastases or cirrhosis). Unbroken line: Mean for all patients (n = 25). Dotted line: Mean for six patients with highest predrainage serum bilirubin values. Broken line: Mean for six patients with lowest predrainage serum bilirubin values.
60
HANSSON AND OTHERS
In group 2 catheter displacement occurred in seven patients, twice in one patient, and five times in one. The displacement was discovered early in each case and replacement was carried out while the catheter was still in the bile duct. In group 2 obstruction of holes in the catheter was common during the long drainage period. Bile flow could easily be re-established by flushing, however. To find out whether the caliber of the catheter was large enough to drain the bile, we tested bile flow under various pressures in vitro. By end-hole catheter with an inner diameter of 1.4 mm we obtained a flow of 6.5 ml/ minute with the driving pressure as low as 10 cm H20. With side-holes in the catheter, the flow was increased to 8 mlmin with a pressure of 10 cm H20 or 5.5 ml/min with a pressure of 5 cm H20. The diameter of the catheter therefore seems adequate for our purpose. Although the catheter has an end-hole and multiple side-holes, the bile flow may be hampered by obstruction of the holes in the catheter by detritus. To avoid this, it is necessary to flush the catheter at least twice a day. Flushing is done with at least 20 ml of saline each time. The saline is forcefully injected. If it is slowly injected, only the end-hole is rinsed.
Complications Emergency operation due to bile leakage to the abdominal cavity despite established drainage of the bile ducts was necessary in three patients. No operation was necessitated because of intra-abdominal bleeding. However, one patient, 83 years of age, with nonresectable pancreatic carcinoma, died due to subcapsular and retroperitoneal bleeding. At elective operation after the drainage period, subcapsular hematomas in the liver were disclosed in two patients and one additional patient displayed hematoma in the hepatoduodenal ligament. At angiography after PTC, arterioportal shunts in the liver were disclosed in four patients while small intraparenchymal extravasations (false aneurysms) were evident in two. Cholangitis defined as fever with peaks exceeding 390 combined with chills and tenderness below the right costal arch occurred in nine of the 68 patients in group 1. In group 2 cholangitic attacks were more common and practically every patient with drainage periods of more than four months had at least one attack of cholangitis. Cholangitis was a main contributing factor in the death of one patient.
Discussion The advantage with percutaneous transhepatic cholangiography with external drainage is that the site and nature of the obstruction are revealed and at the same
Ann. Surg. * January 1979
time biliary stasis is relieved. The definitive surgical attack may therefore be performed in an area undisturbed by an initial bile-diverting procedure. The morphologic information may be obtained preoperatively by other methods such as fine-needle transhepatic cholangiography or ERCP. The latter methods do not relieve bile stasis, however, which must then be achieved by surgical means. Our present approach to the jaundiced patient therefore consists of an initial attempt to opacify the bile ducts with a fine needle. If no dilatation of the bile ducts can be demonstrated and the contrast passes freely to the duodenum, the needle is withdrawn and the procedure is completed. Should dilated bile ducts be demonstrated, however, the procedure is continued with a sheathed needle in order to accomplish external drainage. Percutaneous biopsy guided by the cholangiographic finding5 may, moreover, be added to the procedure. During the drainage period the condition of the patient's liver improves. This period may be used to obtain additional informnation, for example by ERCP and/or angiography. The surgeon can therefore become familiar with the type and extent of the lesion prior to definitive surgery. In some patients it may also be evident that the tumor may be inextirpable." 16-19 For most of the patients a drainage period of two weeks resulted in a decrease of the bilirubin level towards the normal. Presence of liver disease in addition to biliary obstruction, for example liver cirrhosis or liver metastasis, seem to prolong the time needed for drainage if patients with these conditions are to be explored at all. The amount of drained bile varied greatly from patient to patient and was without correlation to the degree of jaundice. The amount of bile drained from patients with liver disease other than obstruction was, however, significantly lower. Bile is necessary for proper digestion and moreover has a choleretic effect when secreted to the intestine. Several of our patients therefore were fed the drained bile through a tube or drank it mixed with porter or stout beer. The bile flow may also be jeopardized by displacement of the catheter despite fixation to the skin. Fortunately most catheters stay in the bile ducts where they are initially placed. When the catheter is displaced, it is usually kinked between the liver and the abdominal wall. This may be due to abnormal mobility between the liver and the abdominal wall or possibly to deep inspirations. The displacement may occur suddenly, in which case the entire catheter may leave the biliary duct. Ifthis occurs, the PTC must again be undertaken, from the beginning. Usually, however, the displacement is gradual. It is, therefore, possible
Vol. 189 * No. I
PERCUTANEOUS TRANSHEPATIC BILE DRAINAGE
to disclose the beginning displacement by abdominal survey films without injections of contrast medium. If the catheter starts gliding it is easy to reinsert it with the aid of a guide wire. We therefore take daily survey films in all patients during the first week and replace the catheters which have a tendency to displacement. After the first week catheters seldom slide out. Should a catheter repeatedly glide out of position, it may be exchanged for a catheter with a thicker wall after a few days, when the puncture channel in the liver is wider. A suitable catheter for this purpose is a polyethylene catheter of OD 2.8 mm. The latter catheter is seldom displaced and has the further advantage of being usable for drainage during lengthy periods when bile leakage around the OD 2.2 mm catheter may occur. A better solution to the displacement problem would be, for example, a balloon catheter giving internal fixation. The balloon catheters presently in use are, however, too poorly aligned at the tip and may not be introduced through the liver. In the previously reported series, the immediate complications were analyzed. Intraperitoneal bile leakage demanding surgical exploration occurred in two out of 83 patients.20 In this extended series an additional patient was operated upon because of bile leakage. One patient with an inoperable carcinoma of the pancreas died due to bleeding. The incidence of severe complications in the study was 4/105. This is in line with the very large series of PTC reported by Marions and Wiechel.1" This exceeds the incidence of complications in the fine needle PTC technique when drainage is not carried out.2.15 In the previous report20 the incidence of cholangitis was very low but the entire drainage period was not evaluated. In the present investigation the incidence of cholangitis during the entire drainage period was analysed. Cholangitis was evident in about 25% of the patienfs. Almost all patients included in group 2, with prolonged drainage, had at least one attack of cholangitis. In one patient in group 2 (the patient whose condition deteriorated rapidly after bile diversion) cholangitis definitely contributed to the fatal outcome. In all other patients the cholangitic attack disappeared rapidly either spontaneously or after antibiotic therapy. The more common bacteria isolated from the patients with cholangitis were Staphylococcus aureus, Enterobacteriae, and Pseudomonas eruginosa. With this high incidence of cholangitis, prophylactic antibiotic treatment may be considered. The patients in group 3 had biliodigestive anastomosis, which did not heal properly. The PTC drainage was un-
61
dertaken to divert the bile and to allow for healing of the anastomosis. To ensure this it is also possible to pass the catheter through the anastomosis, accomplishing partial internal drainage.6'13 References 1. Ariyama, J., Shirakabe, H., Ikenobe, H., Kurosawa, A. and Owman, T.: The Diagnosis of the Small Resectable Pancreatic Carcinoma. Clin. Radiol., 28:437, 1977. 2. Ariyama, J., Shirakabe, H., Ohashi, K. and Roberts, G. M.: Experience with Percutaneous Transhepatic Cholangiography Using the Japanese Needle. Gastrointest. Radiol.,2:359, 1978. 3. Burcharth, F. and Nieblo, N.: Percutaneous Transhepatic Cholangiography with Selective Catheterization of the Common Bile Duct. Am. J. Roentgenol., 127:409, 1976. 4. Burcharth, F., Christiansen, L., Efsen, F., et al.: Percutaneous Transhepatic Cholangiography in Diagnostic Evaluation of 160 Jaundiced Patients. Am. J. Surg., 133:559, 1977. 5. Evander, A., Ihse, I., Lunderquist, A., et al.: Percutaneous Cytodiagnosis of Carcinoma of the Pancreas and Bile Duct. Ann. Surg., 188:90, 1978. 6. Hoevels, J., Lunderquist, A., and Ihse, I.: Percutaneous Transhepatic Intubation of Bile Ducts for Combined InternalExternal Drainage in Preoperative and Palliative treatment of Obstructive Jaundice. Gastrointest. Radiol., 3:23, 1978. 7. Kaude, J. V., Weidenmier, C. H. and Agee, 0. F.: Decompression of Bile Ducts with the Percutaneous Transhepatic Technic. Radiology, 93:69, 1969. 8. Lang, E. K.: Percutaneous Transhepatic Cholangiography. Radiology, 112:283, 1974. 9. Leger, L. and Zara et Arvay, M.: Cholangiographie et Drainage Biliaire par Ponction Trans-hepatique. La Presse med., 42:936, 1952. 10. Marions, 0. and Wiechel, K. L.: Radiological Investigation in Jaundice (in Swedish). Lakartidningen, 70:951, 1973. 11. Marions, 0. and Wiechel, K. L.: Radiological Investigation in Jaundice (in Swedish). Opuscula Medica(Suppl.), XXXII, 1974. 12. Molnar, W. and Stockum, A. E.: Relief of Obstructive Jaundice Through Percutaneous Transhepatic Catheter-a New Therapeutic Method. Am. J. Roentgenol., 122:356, 1974. 13. Mori, K., Misumi, A., Sugiyama, M., et al.: Percutaneous Transhepatic Bile Drainage. Ann. Surg., 185:111, 1977. 14. Mujahed, Z. and Evans, J. A.: Percutaneous Transhepatic Cholangiography. Radiol. Clin. N. Am., 4:535, 1966. 15. Okuda, K., Tanikawa, K., Emura, T., et al.: Nonsurgical Percutaneous Transhepatic Cholangiography -Diagnostic Significance in Medical Problems of the Liver. Am. J. Dig. Dis., 19:21, 1974. 16. Sato, T., Saitoh, Y., Koyama, K. and Watanabe, K.: Preoperative Determination of Operability in Carcinomas of the Pancreas and the Periampullary Region. Ann. Surg., 168:876, 1968. 17. Suzuki, T., Kawabe, K., Nakayasu, A., et al.: Selective Arteriography in Cancer of the Pancreas at a Resectable Stage. Am. J. Surg., 122:402, 1971. 18. Suzuki, T., Kawabe, K., Imamura, M. and Honjo, I.: Survival of Patients with Cancer of the Pancreas in Relation to Findings on Arteriography. Ann. Surg., 176:37, 1972. 19. Tylen, U. and Arnesjo, B.: Resectability and Prognosis of Carcinoma of the Pancreas Evaluated by Angiography. Scand. J. Gastroenterol., 8:691, 1973. 20. Tylen, U., Hoevels, J. and Vang, J.: Percutaneous Transhepatic Cholangiography with External Drainage of Obstructive Biliary Lesions. Surg. Gynecol. Obstet., 144:13, 1977.
From the Departments of Surgery and Diagnostic Radiology, University Hospital, Lund, Sweden
Methods The patient is premedicated with 10 mg Valium® and 0.5 mg Atropin intramuscularly. By fluoroscopy the approximate position of the hilum of the liver is located and at the corresponding level local anesthesia is given in the skin and the intercostal muscles in the right midaxillary line. From this point the procedure is started with a puncture towards the hilum of the liver with a fine needle (OD 0.9 mm, length 15 cm) parallel to the table top and directed towards the estimated position of the liver hilum. As the needle is withdrawn, contrast medium is cautiously injected during fluoroscopy. When filling of nondilated bile ducts is obtained and passage of contrast medium to the duodenum is demonstrated, the procedure is terminated. If dilated bile ducts are filled, the needle is withdrawn and the procedure is continued with a puncture from the same point towards a dilated bile duct with a 27 cm needle sheathed with a polyethylene fluoroscopy with horizontal and vertical beam direction is of great help, since the needle tip can then be placed exactly in a peripheral bile duct. When there is access to single beam fluoroscopy alone the puncture needle is immediately withdrawn and the catheter is gradually retracted until bile drips. A guide wire with a slightly bent soft tip is then advanced through the catheter into the bile duct and manipulated as close as possible to the site of the obstruction. The catheter is pushed over the guide wire, after the removal of which the biliary tree is filled and films are exposed for diagnostic purposes. After demonstration of the site and appearance of the obstruction, the puncture catheter is exchanged for a polyethylene catheter (OD/ID 2.2/1.4 mm) with multiple side-holes close to the tip. The drainage catheter is attached to the skin by sutures and connected to a bag for collection of the drained bile.
pERCUTANEOUS TRANSHEPATIC ACCESS to the biliary
system has provided a satisfactory solution to the problems of palliative bile drainage in unresectable tumors of the extrahepatic bile ducts and the periampullary region.3 4'6'12'20 Via the same route, temporary decompression and bile drainage can be achieved prior to radical operation. 2-4,6-11,13,14,20 In a previous report the technique and complications involved in percutaneous transhepatic cholangiography (PTC) with and without external drainage were reported.20 The present investigation consists of an extended series of patients. The purpose has been to delineate the problems and the advantages in using this drainage procedure.
Subjects The series comprises 105 patients, 60 men and 45 women ranging from 34 to 84 years of age (mean = 50) who had obstructive jaundice and drainage carried out by percutaneous transhepatic technique. A summary of the final diagnosis verified either by operation or postmortem examinations appears in Table 1. * Present address: Department of Surgery, Eksjo-Nassjo Hospital, Eksjo, Sweden. Reprint requests: Jurgen Hoevels, M.D., Department of Diagnostic Radiology, University Hospital. S-221 85 Lund, Sweden. Submitted for publication: June 2, 1978.
0003-4932/79/0100/0058 $01.15 © J. B. Lippincott Company
58
PERCUTANEOUS TRANSHEPATIC BILE DRAINAGE
Vol. 189oNo. I
Results
TABLE 1. Diagnosis in 105 Patients Treated with Nonsurgical Percutaneous Transhepatic Intlubation of the Biliary System
Drainage Time
Group 1. The percutaneous drainage period was followed by operation and biliodigestive anastomosis in 68 patients. The drainage time varied from one day to 150 days (median 15 days) while half of the patients were operated upon within the interval 7-28 days. Group 2. The external bile drainage in 32 patients was not followed by operation with biliodigestive anastomosis. Operation was originally planned in eight of these patients but their condition deteriorated rapidly despite adequate drainage and they died without surgery. Drainage time among the latter eight patients was 2-35 days (median 14 days). The remaining patients in the group had transhepatic drainage as a final palliative procedure. Drainage time among these patients varied from one week to 19 months (median two months) while half of the patients were drained for one to four months. Group 3. This small group comprises five patients in whom the external drainage was arranged as a temporary relief in the postoperative period because of leaking biliodigestive anastomosis. Time of drainage varied from one to eight weeks. Decrease of jaundice. All the patients had varying degrees ofjaundice at the time of PTC. The mean value of bilirubin in serum in the patients in group 1 was 14.8 mg/100 ml before drainage. At the time of operation the mean bilirubin in these patients was reduced to 7.7 mg/100 ml. The mean lowest bilirubin levels during drainage in the patients in group 2 was 6 mg/100 ml. To further analyse the relation between drainage time and the effect of drainage on the level of bilirubin, patients without evidence of liver disease other than that caused by the extrahepatic bile obstruction were selected. In 25 patients (21 from group 1 and four from 2) adequate drainage was established for at least two weeks and during this period several determinations of the bilirubin level were carried out. The results appear in Figure 1. The mean level of serum bilirubin was initially 17 mg/100 ml and after two weeks of drainage it had declined to 5 mg/100 ml. The serum bilirubin concentration could be followed for four weeks in 11 patients and decreased during that period to less than 3 mg/100 ml. The average volume of drained bile in the 25 patients was 610 ml124 hours (range 260-1,220 ml). The drained volume as a rule was the same at the beginning of the period as after two weeks of drainage. There was no correlation between the volume of drained bile and the decrease in bilirubin. The volume of drained bile in a group of 13 patients with liver metastases was also studied. The mean initial value of bilirubin in this latter group was 17 mg/100 ml. After two weeks
59
Diagnosis
Number of Cases
Periampullary carcinoma Carcinoma of the proximal part of the extrahepatic bile ducts and gallbladder Malignant tumor of the liver. Metastases to hepatoduodenal ligament latrogenic strictures of the bile duct Choledocholithiasis Cirrhosis Chronic pancreatitis
49
Total
105
24 12 10 6 3 I
ofdrainage the level was 9 mg/I00 ml. The mean volume of drained bile was 360 ml/24 hours (range 160-625 ml). During the first week of drainage bilirubin decreased rapidly. Decline is less marked after about two weeks. The degree ofjaundice at the time of PTC seems to be of minor importance since patients with high initial bilirubin levels reached approximately the same level after two weeks of drainage as those patients who initially had the lowest levels of bilirubin (Fig. 1). Catheter problems delayed the decrease in bilirubin in 11 patients in group 1. Catheter displacement necessitated reposition of the catheter in five patients, in two of these on two occasions. In the remaining cases the holes in the catheter were obstructed by detritus. The bile flow could be re-established by flushing the catheter. mg/dl 25
20
15
10
0
Time. days
FIG. 1. Total serum bilirubin concentration during drainage period of 14 days in a group of 25 patients with satisfactory drainage function and healthy liver (i.e. without metastases or cirrhosis). Unbroken line: Mean for all patients (n = 25). Dotted line: Mean for six patients with highest predrainage serum bilirubin values. Broken line: Mean for six patients with lowest predrainage serum bilirubin values.
60
HANSSON AND OTHERS
In group 2 catheter displacement occurred in seven patients, twice in one patient, and five times in one. The displacement was discovered early in each case and replacement was carried out while the catheter was still in the bile duct. In group 2 obstruction of holes in the catheter was common during the long drainage period. Bile flow could easily be re-established by flushing, however. To find out whether the caliber of the catheter was large enough to drain the bile, we tested bile flow under various pressures in vitro. By end-hole catheter with an inner diameter of 1.4 mm we obtained a flow of 6.5 ml/ minute with the driving pressure as low as 10 cm H20. With side-holes in the catheter, the flow was increased to 8 mlmin with a pressure of 10 cm H20 or 5.5 ml/min with a pressure of 5 cm H20. The diameter of the catheter therefore seems adequate for our purpose. Although the catheter has an end-hole and multiple side-holes, the bile flow may be hampered by obstruction of the holes in the catheter by detritus. To avoid this, it is necessary to flush the catheter at least twice a day. Flushing is done with at least 20 ml of saline each time. The saline is forcefully injected. If it is slowly injected, only the end-hole is rinsed.
Complications Emergency operation due to bile leakage to the abdominal cavity despite established drainage of the bile ducts was necessary in three patients. No operation was necessitated because of intra-abdominal bleeding. However, one patient, 83 years of age, with nonresectable pancreatic carcinoma, died due to subcapsular and retroperitoneal bleeding. At elective operation after the drainage period, subcapsular hematomas in the liver were disclosed in two patients and one additional patient displayed hematoma in the hepatoduodenal ligament. At angiography after PTC, arterioportal shunts in the liver were disclosed in four patients while small intraparenchymal extravasations (false aneurysms) were evident in two. Cholangitis defined as fever with peaks exceeding 390 combined with chills and tenderness below the right costal arch occurred in nine of the 68 patients in group 1. In group 2 cholangitic attacks were more common and practically every patient with drainage periods of more than four months had at least one attack of cholangitis. Cholangitis was a main contributing factor in the death of one patient.
Discussion The advantage with percutaneous transhepatic cholangiography with external drainage is that the site and nature of the obstruction are revealed and at the same
Ann. Surg. * January 1979
time biliary stasis is relieved. The definitive surgical attack may therefore be performed in an area undisturbed by an initial bile-diverting procedure. The morphologic information may be obtained preoperatively by other methods such as fine-needle transhepatic cholangiography or ERCP. The latter methods do not relieve bile stasis, however, which must then be achieved by surgical means. Our present approach to the jaundiced patient therefore consists of an initial attempt to opacify the bile ducts with a fine needle. If no dilatation of the bile ducts can be demonstrated and the contrast passes freely to the duodenum, the needle is withdrawn and the procedure is completed. Should dilated bile ducts be demonstrated, however, the procedure is continued with a sheathed needle in order to accomplish external drainage. Percutaneous biopsy guided by the cholangiographic finding5 may, moreover, be added to the procedure. During the drainage period the condition of the patient's liver improves. This period may be used to obtain additional informnation, for example by ERCP and/or angiography. The surgeon can therefore become familiar with the type and extent of the lesion prior to definitive surgery. In some patients it may also be evident that the tumor may be inextirpable." 16-19 For most of the patients a drainage period of two weeks resulted in a decrease of the bilirubin level towards the normal. Presence of liver disease in addition to biliary obstruction, for example liver cirrhosis or liver metastasis, seem to prolong the time needed for drainage if patients with these conditions are to be explored at all. The amount of drained bile varied greatly from patient to patient and was without correlation to the degree of jaundice. The amount of bile drained from patients with liver disease other than obstruction was, however, significantly lower. Bile is necessary for proper digestion and moreover has a choleretic effect when secreted to the intestine. Several of our patients therefore were fed the drained bile through a tube or drank it mixed with porter or stout beer. The bile flow may also be jeopardized by displacement of the catheter despite fixation to the skin. Fortunately most catheters stay in the bile ducts where they are initially placed. When the catheter is displaced, it is usually kinked between the liver and the abdominal wall. This may be due to abnormal mobility between the liver and the abdominal wall or possibly to deep inspirations. The displacement may occur suddenly, in which case the entire catheter may leave the biliary duct. Ifthis occurs, the PTC must again be undertaken, from the beginning. Usually, however, the displacement is gradual. It is, therefore, possible
Vol. 189 * No. I
PERCUTANEOUS TRANSHEPATIC BILE DRAINAGE
to disclose the beginning displacement by abdominal survey films without injections of contrast medium. If the catheter starts gliding it is easy to reinsert it with the aid of a guide wire. We therefore take daily survey films in all patients during the first week and replace the catheters which have a tendency to displacement. After the first week catheters seldom slide out. Should a catheter repeatedly glide out of position, it may be exchanged for a catheter with a thicker wall after a few days, when the puncture channel in the liver is wider. A suitable catheter for this purpose is a polyethylene catheter of OD 2.8 mm. The latter catheter is seldom displaced and has the further advantage of being usable for drainage during lengthy periods when bile leakage around the OD 2.2 mm catheter may occur. A better solution to the displacement problem would be, for example, a balloon catheter giving internal fixation. The balloon catheters presently in use are, however, too poorly aligned at the tip and may not be introduced through the liver. In the previously reported series, the immediate complications were analyzed. Intraperitoneal bile leakage demanding surgical exploration occurred in two out of 83 patients.20 In this extended series an additional patient was operated upon because of bile leakage. One patient with an inoperable carcinoma of the pancreas died due to bleeding. The incidence of severe complications in the study was 4/105. This is in line with the very large series of PTC reported by Marions and Wiechel.1" This exceeds the incidence of complications in the fine needle PTC technique when drainage is not carried out.2.15 In the previous report20 the incidence of cholangitis was very low but the entire drainage period was not evaluated. In the present investigation the incidence of cholangitis during the entire drainage period was analysed. Cholangitis was evident in about 25% of the patienfs. Almost all patients included in group 2, with prolonged drainage, had at least one attack of cholangitis. In one patient in group 2 (the patient whose condition deteriorated rapidly after bile diversion) cholangitis definitely contributed to the fatal outcome. In all other patients the cholangitic attack disappeared rapidly either spontaneously or after antibiotic therapy. The more common bacteria isolated from the patients with cholangitis were Staphylococcus aureus, Enterobacteriae, and Pseudomonas eruginosa. With this high incidence of cholangitis, prophylactic antibiotic treatment may be considered. The patients in group 3 had biliodigestive anastomosis, which did not heal properly. The PTC drainage was un-
61
dertaken to divert the bile and to allow for healing of the anastomosis. To ensure this it is also possible to pass the catheter through the anastomosis, accomplishing partial internal drainage.6'13 References 1. Ariyama, J., Shirakabe, H., Ikenobe, H., Kurosawa, A. and Owman, T.: The Diagnosis of the Small Resectable Pancreatic Carcinoma. Clin. Radiol., 28:437, 1977. 2. Ariyama, J., Shirakabe, H., Ohashi, K. and Roberts, G. M.: Experience with Percutaneous Transhepatic Cholangiography Using the Japanese Needle. Gastrointest. Radiol.,2:359, 1978. 3. Burcharth, F. and Nieblo, N.: Percutaneous Transhepatic Cholangiography with Selective Catheterization of the Common Bile Duct. Am. J. Roentgenol., 127:409, 1976. 4. Burcharth, F., Christiansen, L., Efsen, F., et al.: Percutaneous Transhepatic Cholangiography in Diagnostic Evaluation of 160 Jaundiced Patients. Am. J. Surg., 133:559, 1977. 5. Evander, A., Ihse, I., Lunderquist, A., et al.: Percutaneous Cytodiagnosis of Carcinoma of the Pancreas and Bile Duct. Ann. Surg., 188:90, 1978. 6. Hoevels, J., Lunderquist, A., and Ihse, I.: Percutaneous Transhepatic Intubation of Bile Ducts for Combined InternalExternal Drainage in Preoperative and Palliative treatment of Obstructive Jaundice. Gastrointest. Radiol., 3:23, 1978. 7. Kaude, J. V., Weidenmier, C. H. and Agee, 0. F.: Decompression of Bile Ducts with the Percutaneous Transhepatic Technic. Radiology, 93:69, 1969. 8. Lang, E. K.: Percutaneous Transhepatic Cholangiography. Radiology, 112:283, 1974. 9. Leger, L. and Zara et Arvay, M.: Cholangiographie et Drainage Biliaire par Ponction Trans-hepatique. La Presse med., 42:936, 1952. 10. Marions, 0. and Wiechel, K. L.: Radiological Investigation in Jaundice (in Swedish). Lakartidningen, 70:951, 1973. 11. Marions, 0. and Wiechel, K. L.: Radiological Investigation in Jaundice (in Swedish). Opuscula Medica(Suppl.), XXXII, 1974. 12. Molnar, W. and Stockum, A. E.: Relief of Obstructive Jaundice Through Percutaneous Transhepatic Catheter-a New Therapeutic Method. Am. J. Roentgenol., 122:356, 1974. 13. Mori, K., Misumi, A., Sugiyama, M., et al.: Percutaneous Transhepatic Bile Drainage. Ann. Surg., 185:111, 1977. 14. Mujahed, Z. and Evans, J. A.: Percutaneous Transhepatic Cholangiography. Radiol. Clin. N. Am., 4:535, 1966. 15. Okuda, K., Tanikawa, K., Emura, T., et al.: Nonsurgical Percutaneous Transhepatic Cholangiography -Diagnostic Significance in Medical Problems of the Liver. Am. J. Dig. Dis., 19:21, 1974. 16. Sato, T., Saitoh, Y., Koyama, K. and Watanabe, K.: Preoperative Determination of Operability in Carcinomas of the Pancreas and the Periampullary Region. Ann. Surg., 168:876, 1968. 17. Suzuki, T., Kawabe, K., Nakayasu, A., et al.: Selective Arteriography in Cancer of the Pancreas at a Resectable Stage. Am. J. Surg., 122:402, 1971. 18. Suzuki, T., Kawabe, K., Imamura, M. and Honjo, I.: Survival of Patients with Cancer of the Pancreas in Relation to Findings on Arteriography. Ann. Surg., 176:37, 1972. 19. Tylen, U. and Arnesjo, B.: Resectability and Prognosis of Carcinoma of the Pancreas Evaluated by Angiography. Scand. J. Gastroenterol., 8:691, 1973. 20. Tylen, U., Hoevels, J. and Vang, J.: Percutaneous Transhepatic Cholangiography with External Drainage of Obstructive Biliary Lesions. Surg. Gynecol. Obstet., 144:13, 1977.
