Direct Injection Into the Gallbladder in Dogs, Using Ultrasonic Guidance Michael T. Hogan, MD; Alvin Watne, MD; William Mossburg, MD; Wilfrido Castaneda, MD
\s=b\ Direct injection into the gallbladder can be accomplished with the guidance of the ultrasonic aspiration transducer. Possible bile peritonitis is a limiting factor, but not necessarily a complication that contraindicates the procedure. Some modifications of the procedure may be necessary, and further investigation into this potentially valuable procedure is indicated.
(Arch Surg 111:564-565, 1976)
differential diagnosis of obstructive and nonobstructive jaundice is still a perplexing problem. Percu¬ taneous transhepatic cholangiography often provides the correct diagnosis, but it is, in part, a blind procedure. Because the ultrasonic aspiration transducer provides direct visualization and has been used successfully in several procedures in a number of organs,1 we attempted to use this procedure to inject directly into the gallbladder.
The
MATERIALS AND METHODS Ten dogs were used for this preliminary investigation. Each dog fasted for 12 to 15 hours prior to the procedure and was subjected to pentobarbital sodium anesthesia. After localization of the gallbladder with ultrasound, an 18-gauge needle was inserted through the transducer into the gallbladder and 12 ml of diatrizoate meglumine and diatrizoate sodium (Renografin-60) was injected. A plain abdominal roentgenogram was then obtained. The dogs underwent immediate laparotomy, with a second lapa¬ rotomy one week later. was
RESULTS AND COMMENT
The studies in
eight dogs
were
technically
successful.
publication Oct 24, 1975. departments of radiology (Drs Hogan and Castaneda) and surgery (Drs Watne and Mossburg), West Virginia University Hospital, Morgantown. Dr Mossburg is now with Highlands Clinic, Williamson, WVa, and Dr Castaneda is now with University Hospitals, Minneapolis. Reprint requests to West Virginia University Hospital, Morgantown, WV 26506 (Dr Hogan). Accepted
for
From the
After
of contrast material into gallbladder, gallbladder, bile duct, and duct's entrance into small bowel are well
Injection
common
demonstrated.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/14/2015
After experience had been gained, it could be determined within a few minutes whether or not the puncture would be successful. The success depended on adequate visualization of the gallbladder ultrasonically. When the injection was successful, there was good visualization of the gallbladder and common bile duct (Figure). We believe that actually puncturing the gallbladder (only if definitely seen) does not present a problem and should be as simple as renal cyst
puncture. The
major question is, does the risk outweigh the advantages? As with transhepatic cholangiography, bile peritonitis is a possibility. However, with transhepatic cholangiography, accidental puncture of the gallbladder or extrahepatic bile ducts may occur.1' Also, as with transhe¬ patic cholangiography, the patient would undergo an immediate laparotomy unless the results indicated other¬ wise. If an obstruction was found, a corrective procedure would be performed. One dog died of bile peritonitis. Three dogs had appre¬ ciable bile leakage that was noted at surgery; spontaneous closure of the leak occurred. None of the dogs had a biliary tract obstruction. In the human, we would attempt to
intrahepatic side of the and Müller' used this technique of percutaneous puncture of the gallbladder on three patients and believed that with proper care, it might be a useful study. This approach was not used in the dogs. As a modification of the procedure, a catheter extending from the gallbladder to the skin could be inserted. This would not affect the patients with obstructive jaundice since this would still undergo laparotomy. In the patients with nonobstructive jaundice, the catheter would function like a cholecystostomy tube allowing repeated injection of contrast material. A tract would form for the tube to be removed, thus protecting against bile peritonitis. traverse the liver and enter the
gallbladder. Burkhardt
References 1. Goldberg BB, Pollack H: Ultrasonic aspiration: Biopsy transducer. Radiology 108:667-671, 1973. 2. Evans J: Transhepatic cholangiography, in Margulis A, Burhenne H (eds): Alimentary Tract Roentgenology. St Louis, CV Mosby Co, 1973, pp 1339-1358. 3. Burkhardt H, Muller W, cited by Evans J: Transhepatic cholangiography, in Margulis A, Burhenne H (eds): Alimentary Tract Roentgenology. St Louis, CV Mosby Co, 1973, p 1339.
Invited Editorial Comment The problem of opacifying the biliary tree in the jaundiced patient remains a perplexing one. Any new approach is welcome. The approach the authors have taken, that of opacifying the gallbladder and common bile duct via ultrasonically guided punc¬ ture, is a clever one, and is certainly technically feasible in the laboratory (eight of ten successes); it should be easily accomplished
in the human, as well. However, the procedure is potentially somewhat less useful than the transhepatic cholangiogram, since the intrahepatic biliary radicals are not opacified. Furthermore, the latter procedure can now be performed with a small needle under ultrasound guidance
requiring routine immediate exploratory laparotomy. Certainly, the death of one of eight dogs from peritonitis indicates the need for further investigation of the safety of this procedure before its application to humans. The next logical step would be to assess its safety after ligation of the common duct in the laboratory animal. If the procedure proves to be reasonably safe, it may be an alternative to transhepatic cholangiography in certain
without
circumstances.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/14/2015
Edward H. Boston
Smith, MD
\s=b\ Direct injection into the gallbladder can be accomplished with the guidance of the ultrasonic aspiration transducer. Possible bile peritonitis is a limiting factor, but not necessarily a complication that contraindicates the procedure. Some modifications of the procedure may be necessary, and further investigation into this potentially valuable procedure is indicated.
(Arch Surg 111:564-565, 1976)
differential diagnosis of obstructive and nonobstructive jaundice is still a perplexing problem. Percu¬ taneous transhepatic cholangiography often provides the correct diagnosis, but it is, in part, a blind procedure. Because the ultrasonic aspiration transducer provides direct visualization and has been used successfully in several procedures in a number of organs,1 we attempted to use this procedure to inject directly into the gallbladder.
The
MATERIALS AND METHODS Ten dogs were used for this preliminary investigation. Each dog fasted for 12 to 15 hours prior to the procedure and was subjected to pentobarbital sodium anesthesia. After localization of the gallbladder with ultrasound, an 18-gauge needle was inserted through the transducer into the gallbladder and 12 ml of diatrizoate meglumine and diatrizoate sodium (Renografin-60) was injected. A plain abdominal roentgenogram was then obtained. The dogs underwent immediate laparotomy, with a second lapa¬ rotomy one week later. was
RESULTS AND COMMENT
The studies in
eight dogs
were
technically
successful.
publication Oct 24, 1975. departments of radiology (Drs Hogan and Castaneda) and surgery (Drs Watne and Mossburg), West Virginia University Hospital, Morgantown. Dr Mossburg is now with Highlands Clinic, Williamson, WVa, and Dr Castaneda is now with University Hospitals, Minneapolis. Reprint requests to West Virginia University Hospital, Morgantown, WV 26506 (Dr Hogan). Accepted
for
From the
After
of contrast material into gallbladder, gallbladder, bile duct, and duct's entrance into small bowel are well
Injection
common
demonstrated.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/14/2015
After experience had been gained, it could be determined within a few minutes whether or not the puncture would be successful. The success depended on adequate visualization of the gallbladder ultrasonically. When the injection was successful, there was good visualization of the gallbladder and common bile duct (Figure). We believe that actually puncturing the gallbladder (only if definitely seen) does not present a problem and should be as simple as renal cyst
puncture. The
major question is, does the risk outweigh the advantages? As with transhepatic cholangiography, bile peritonitis is a possibility. However, with transhepatic cholangiography, accidental puncture of the gallbladder or extrahepatic bile ducts may occur.1' Also, as with transhe¬ patic cholangiography, the patient would undergo an immediate laparotomy unless the results indicated other¬ wise. If an obstruction was found, a corrective procedure would be performed. One dog died of bile peritonitis. Three dogs had appre¬ ciable bile leakage that was noted at surgery; spontaneous closure of the leak occurred. None of the dogs had a biliary tract obstruction. In the human, we would attempt to
intrahepatic side of the and Müller' used this technique of percutaneous puncture of the gallbladder on three patients and believed that with proper care, it might be a useful study. This approach was not used in the dogs. As a modification of the procedure, a catheter extending from the gallbladder to the skin could be inserted. This would not affect the patients with obstructive jaundice since this would still undergo laparotomy. In the patients with nonobstructive jaundice, the catheter would function like a cholecystostomy tube allowing repeated injection of contrast material. A tract would form for the tube to be removed, thus protecting against bile peritonitis. traverse the liver and enter the
gallbladder. Burkhardt
References 1. Goldberg BB, Pollack H: Ultrasonic aspiration: Biopsy transducer. Radiology 108:667-671, 1973. 2. Evans J: Transhepatic cholangiography, in Margulis A, Burhenne H (eds): Alimentary Tract Roentgenology. St Louis, CV Mosby Co, 1973, pp 1339-1358. 3. Burkhardt H, Muller W, cited by Evans J: Transhepatic cholangiography, in Margulis A, Burhenne H (eds): Alimentary Tract Roentgenology. St Louis, CV Mosby Co, 1973, p 1339.
Invited Editorial Comment The problem of opacifying the biliary tree in the jaundiced patient remains a perplexing one. Any new approach is welcome. The approach the authors have taken, that of opacifying the gallbladder and common bile duct via ultrasonically guided punc¬ ture, is a clever one, and is certainly technically feasible in the laboratory (eight of ten successes); it should be easily accomplished
in the human, as well. However, the procedure is potentially somewhat less useful than the transhepatic cholangiogram, since the intrahepatic biliary radicals are not opacified. Furthermore, the latter procedure can now be performed with a small needle under ultrasound guidance
requiring routine immediate exploratory laparotomy. Certainly, the death of one of eight dogs from peritonitis indicates the need for further investigation of the safety of this procedure before its application to humans. The next logical step would be to assess its safety after ligation of the common duct in the laboratory animal. If the procedure proves to be reasonably safe, it may be an alternative to transhepatic cholangiography in certain
without
circumstances.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/14/2015
Edward H. Boston
Smith, MD
