1040

NON-SURGICAL TREATMENT OF BILIARY OBSTRUCTION R. DICK J. S. DOOLEY S. OLNEY SHERLOCK J. and Radiology, Royal Free Hospital, Departments of Medicine London NW3

Bileduct catheterisation percutaneously through the liver can be used in patients with obstructive jaundice as an adjunct or as an alternative to surgery. Preoperative drainage allows adequate treatment of severe cholangitis and reduces jaundice. Palliative drainage, whether internal or external, can be used instead of surgery. Drainage through the liver succeeded in 40 of 41 patients. Two complications followed the procedure and were treated conservatively. Bile drainage was established through an endoprosthesis into the duodenum in 7 patients and externally through a catheter in the remaining 33. The technique is described, and its use in patients with suppurative cholangitis and benign and malignant biliary strictures is illustrated.

Summary

Introduction SURGERY in patients with obstructive jaundice is - associated with an increased risk of postoperative complications.1,2 Palliative surgery for carcinoma of the pancreas carries an operative mortality of 33%, and if widespread metastases are present this rises to 59%.2 The risk of postoperative acute renal failure is increased in the presence of obstructive jaundice,’ and this is thought to be due to retained bile components. Percutaneous transhepatic biliary drainage can relieve biliary obstruction and might be useful in such patients before surgery. Furthermore, ’Teflon’ or polyvinyl tubes can be introduced under X-ray screening through biliary strictures, obviating the need for surgery in some patients. This paper describes the management of patients with obstructive jaundice by means of percu,

taneous trans-

hepatic drainage.

Diagnostic Procedure If bileduct obstruction is suspected, grey-scale ultrasound is the first procedure (fig. 1). This differentiates between obstructive and non-obstructive jaundice in over 90% of patients.4,5 Minimal duct dilatation--due,

6. Calne RY, White DJG, Rolles K, Smith DP, Herbertson BM. Prolonged survival of pig orthotopic heart grafts treated with cyclosporin A. Lancet 1978; i: 1183-85. 7. Dunn DC, White DJG, Wade J. Survival of first and second kidney allografts after withdrawal of cyclosporin A therapy. IRCS Med Sci 1978; 6: 464. 8. Green CJ, Allison AC, Precious S. Induction of specific tolerance in rabbits by kidney allografting and short period of cyclosporin-A treatment. Lancet 1979; ii: 123-25. 9. Calne RY, White DJG, Thiru S, et al. Cyclosporin A in patients receiving renal allografts from cadaver donors. Lancet 1978; ii: 1323-26. 10. Powles RL, Barrett AJ, Clink H, Kay HEM, Sloane J, McElwain TJ. Cyclosporin A for the treatment of graft-versus-host disease in man. Lancet 1978; ii: 1327-29. 11. Tutschka PJ, Beschorner WE, Allison AC, Burns WH, Santos GW. Use of cyclosporin A in allogeneic bone marrow transplantation in the rat. Nature 1979; 280: 148-51. 12. Borel JF, Wiesenger D. Effect of cyclosporin A on murine lymphoid cells. In: Lucas DO, ed. Regulatory mechanisms in lymphocyte activation. New York: Academic Press, 1977: 716-18.

Fig. 1—Management

of

patient with bileduct obstruction.

for instance, to a calculus-may not be detected. When dilated bileducts are found cholangiography is the next procedure, and percutaneous transhepatic cholangiography (PTC) is the technique of choice. Endoscopic retrograde cholangiography (ERC) in this situation can be followed by cholangitis. After the presence and site of bileduct obstruction have been confirmed, the choice of subsequent management lies between immediate surgery, bileduct drainage followed by surgery, and palliative long-term drainage, either externally or internally through a prosthesis. External

Drainage

Local anxsthesia is used, together with intravenous benzodiazepine and pethidine if necessary. Chiba or skinny-needle cholangiography is done. If the ducts are obstructed, a catheter-over-needle assembly (length 27 cm, Fr. 5, Surgimed) is directed under X-ray screening into a selected major hepatic duct. Lateral views are obligatory to show the anteroposterior position of the duct and therefore the plane along which the needle should be introduced. When the catheter is within a duct a guide wire replaces the stilette and is passed further into the biliary system. The initial catheter is removed and the final catheter (Cook’s Pigtail French 8 with six side holes) is introduced. The catheter is secured at the skin with adhesive tape, which gives more stability than silk stitches. Bile drains into a bag beside the patient. A sample is taken immediately for gram staining and aerobic and anaerobic culture. Prophylactic antibiotic cover is given only if calculous obstruction is suspected or if there is an anastomosis between biliary system and bowel, the risk of biliary infection then being high.6

13. Borel

JF, Fuerer C, Magnee C, Stahelin H. Effects of the new anti-lymphocytic peptide cyclospurin A in animals. Immunology 1977; 32: 1017-25. 14. Burckhardt JJ, Guggenheim B. Cyclosporin A: in vivo and in vitro suppression of rat T-lymphocyte function. Immunology 1979, 36: 753-57. 15. Markwick JR, Barnes RMR, Pegrum GD. Allogeneic cell interactions in the rat. I. Changes in the rate of cell proliferation during local graft-versushost and host-versus-graft reactions. Cell Immunol 1977; 32: 52-59. 16. Ford WL, Burr W, Simonsen M. A lymph node weight assay for the graft-versus-host activity of rat lymphoid cells. Transplantation 1970; 10: 258-66. 17. Yamamura M, Nikbin B, Hobbs JR. Standardisation of the mixed lymphocyte reaction. J Immunol Methods 1978; 10: 367-78. 18. Soulillou JP, Carpenter CB, Lundin AP, Strom TB. Augmentation of proliferation and in vitro production of cytotoxic cells by 2-ME in the rat. J

Immunol 1975; 115: 1566-71. 19. Rolstad B. The host component of the graft-versus-host reaction. A study of the popliteal lymph node reaction in the rat. Transplantation 1976, 21: 117-23. 20. Grebe SC, Streilein JW. Disseminated systemic expression of the ’local’ popliteal lymph node assay in rats. Transplantation 1976; 22: 245-55.

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The patient remains in bed for 24 h after the procedThe normal bile flow is 500-1000 ml per day and initially may be more. Sodium and water balance are carefully maintained during the period of drainage, and parenteral replacement is sometimes necessary. ure.

Internal

Drainage

The patient is prepared as for external drainage. The guide wire is passed through the stricture into the lower common bileduct or duodenum. A tapered dilator (35 cm long, Fr. 8, Cooks) is then passed over the guide wire, and the endoprosthesis is advanced over both by means of a length of tubing of similar calibre to the prosthesis. Once the endoprosthesis is in position so that it will allow drainage of bile into the lower common bileduct or duodenum, the guide wire and dilator are removed. The endoprosthesis currently used is the Lunderquist-T-Owman endoprosthesis (10 cm long, external diameter 4 mm, internal diameter 3

mm). If the lumen of the stricture cannot be found, external for 7 to 10 days often results in the reduction of œdema at the obstruction, and internal drainage is then feasible. Internal drainage avoids the fluid-balance problems encountered with external drainage and may be used as the definitive procedure in a patient with inoperable obstruction.

drainage

Results

Catheterisation of the biliary system succeeded in 40 of 41 patients (fig. 2). In 1 patient, catheterisation was terminated when bleeding occurred through the catheter, which was then removed. The patient underwent surgery the same day, without complications. 30 of the 40 patients had malignant biliary obstruction. 2 developed complications-1 biliary peritonitis and the other septicaemia. Neither required surgical intervention. 21 of the 33 patients drained externally subsequently underwent surgery. The overall operative mortality in this group was 24%. Endoprostheses were inserted in 7 patients, and internal drainage was established in 6. Deaths in this group were due to the underlying malignancy and not cholestasis.

Fig. 3—PTC in patient with calculus at lower end of common bileduct (C) and extravasation of contrast into abscess (A). cation for external drainage. Decompression is monitored. These patients will eventually come to surgery.

Case-report.-A 54-year-old man presented with a threeweek history of intermittent jaundice, fever, and weight loss. On examination he was jaundiced and febrile. There was a 4 cm hepatomegaly. Grey-scale ultrasound demonstrated a dilated biliary system. Percutaneous transhepatic cholangiography (fig. 3) showed a calculus obstructing the lower end of the common bileduct and also intrahepatic abscesses. A Cook’s pigtail french 8 catheter was introduced into the common bileduct, and external drainage was established (fig. 4). Parenteral antibiotics were continued, and the fever and jaundice subsided. At laparotomy eight days later, the gallbladder contained a large stone. Cholecystectomy was performed. Multiple stones were found in the common bileduct, and a wide sphinc-

Types of Obstruction Biliary Obstruction due to a Gallstone With undilated bileducts, early surgery or endoscopic papillotomy are routine. If the bileducts are dilated, the

physician has the choice of percutaneous drainage and surgery. Cholangitis with septicaemia is an absolute indi-

Fig. 2-Results of percutaneous transhepatic biliary drainage in 41 patients.

Fig. 4-Drainage duct.

catheter

(arrow)

in

position in

common

bile-

1042

teroplasty

was

fashioned and the

stones were

washed

out.

His

postoperative course was uncomplicated.

Benign Biliary Stricture Benign biliary stricture is usually managed surgically without preliminary biliary drainage. However, if acute infection is present then preoperative percutaneous drainage and antibiotics are essential. Many patients have had multiple operations, so surgical repair becomes increasingly difficult. In such patients relief of the stricture with an endoprosthesis, introduced percutaneously, should be considered.

Case-report.-In November, 1978, a biliary fistula developed in a 5 S-year-old man after a cholecystectomy for gallstones. In January, 1979, the fistula closed and the patient became jaundiced. A hepatico-jejunostomy en-roux was performed to relieve the stricture. In April, 1979, jaundice recurred. Percutaneous transhepatic cholangiography was done, and the dilated intrahepatic ducts were entered (fig. 5). No contrast flowed through the surgical anastomosis into the jejunum, and external biliary drainage was instituted. At cholangiography, five days later, the stricture was visualised and an internal prosthesis inserted (fig. 6). The patient remains well and free of jaundice three months later.

6-Same patient as in fig. 5: internal drainage of contrast.

Fig.

endoprosthesis (arrow)

with

for duodenal ulcer, and a cholecystectomy. Investigations showed total bilirubin 549 µmo1/1. Grey-scale ultrasound demonstrated bile duct dilatation. In view of his age, the past history of coronary-artery disease, and the high serum bilirubin level, external biliary drainage was established before elec-

plasty

Operable Malignant Bileduct Obstruction A surgical bypass remains the usual management for malignant biliary obstruction due to carcinoma of the pancreas or bileducts. Preoperative drainage may be useful in reducing the frequency of postoperative renal failure and for patients whose general condition does not permit surgery. Operative complications are increased when serum bilirubin levels exceed 170 µmol/1 (10 mg/dl).’ In deeply jaundiced patients external drainage for about a week allows operation to take place with undilated ducts and reduced jaundice. Case-report.-In January, 1979, a 73-year-old man presented with a three-week history of jaundice and itching. He had had two myocardial infarctions, a vagotomy and pyloro-

tive surgery. Percutaneous transhepatic cholangiography confirmed malignant obstruction, and a Cook’s pigtail catheter was inserted. The daily volume of bile drained was 250-500 ml. Bile replacement was given first through a nasogastric tube and later, orally, mixed in a special cocktail to disguise the bitter taste. The patient persisted with this for a week but then would not tolerate it and the bile replacement was stopped. After sixteen days cholangiography showed a reduction in the size of bile ducts. Cytological examination of tissue aspirated by fine needle from the site of obstruction showed malignant cells. After 21 days the serum bilirubin had fallen to 97 µmo1/1 (fig. 7). At surgery a large carcinoma of the head of the pancreas was found, and a choledochoenterostomy with enteroanastomosis was performed. He was discharged from hospital 15 days later.

uays

Fig. 5-Skinny-needle PTC (arrow).

in

patient

with hilar stricture

Fig. 7-Fall in serum-bilirubin concentration patient with malignant bileduct obstruction.

after

drainage

in

1043

Inoperable Malignant Bileduct Obstruction Palliative long-term biliary drainage may be done when the patient is too ill for surgery, when surgery has failed,

or

when obstruction has recurred after

an

earlier

bypass operation. If possible, internal biliary drainage with a prosthesis should be established and external drainage used only when this is impossible. Drainage will not only improve liver function but also control the intractable pruritus. a 44-year-old man had a for relief of hepatico-jejunostomy biliary obstruction due to adenocarcinoma of the bileducts at. the hilum of the liver. In April, 1978, jaundice recurred, and at surgery a polyethylene tube was inserted through the growth. He remained well until July, 1978, when jaundice recurred after passage of the plastic tube with his motions. Percutaneous internal drainage failed, so external drainage was established with a catheter and continued for eight months. Biliary obstruction was relieved and itching controlled. Adequate biliary drainage of 900 ml per day continued, and salt balance was maintained with oral salt supplements. Abdominal pain became increasingly severe. He died from spread of the carcinoma.

Case-report.-In November, 1977,

Discussion

Non-surgical biliary drainage may precede and reduce. the risk of elective surgery, or it can replace surgery in selected patients. The acceptance of such procedures depends on the balance between the risk and the benefit to the patient. In the majority of patients with underlying malignant disease the prognosis is poor and an assessment of benefit is difficult. Catheterisation of dilated bileducts is not technically difficult.1,7-9 Nakayama et al.1 report only 1 failure in 105 attempts. We have had 1 failure in 41 patients. Success depends on the experience of the radiologist and on the degree of dilatation of the duct system.’ The rightflank approach is now used in most centres. The anterior approach, in which a sheathed needle is directed vertically downwards subcostally into the duct system, was described by Takada but is often impracticable when the major hepatic ducts lie under the rib margin. Reported complications include intraperitoneal bile leakage and haemorrhage, cholangitis, and pneumothorax. The overall incidence is 4-5%.1,8 Our experience is similar and no patient died as a result of catheterisation. Pneumothorax can be avoided by ensuring that the point of entry for the sheathed needle is below the costophrenic angle. Later complications are not as well documented. Straight catheters often become dislodged, but with the present choice of the Cook’s pigtail catheter well

strapped to the skin, displacement is unusual. The stability appears to be reduced in the presence of hepatic metastases or sclerosing cholangitis. Sodium and water lost with external drainage need to be replaced. Intravenous replacement is usually necessary for the first few days. Oral ingestion of the bile, in a cocktail or through a nasogastric tube, would avoid these problems, but patients are usually unwilling to tolerate either method for long. Hansson et awl. recommend that the bile be taken mixed with stout beer. Postoperative pulmonary emboli have occurred and, although they cannot be directly related to the drainage, recumbency during this period should be avoided. Cholangitis may complicate external drainage, particularly in patients in whom palliative drainage is continued for more than four months.8

Whether preoperative biliary drainage reduces the mortality and morbidity of subsequent surgery has not been established. It is our opinion that when cholangitis and septicaemia coexist with biliary obstruction, catheter decompression is indicated. There is still doubt, however, whether preoperative biliary drainage will benefit the patient with uncomplicated malignant biliary obstruction. The operative mortality for palliative surgery in this group has been reported as 33% and higher:2 a proportion of this is due to the malignancy itself, and drainage is of no help. However, there is both clinical and experimental evidence that the remaining mortality and morbidity after surgery is due to the retention of bile components such as bilirubin and bile salts. Dawson3 reported that the risk of renal impairment after surgery in patients with obstructive jaundice is higher than in patients undergoing other abdominal surgery. Experimentally, high serum concentrations of bilirubin and bile salts make the tubules more sensitive to insults such as hypotension.lO The presence of obstructive jaundice also changes vascular responses to sympathomimetic agents,1l,12 but the causes have not been identified. Nakayama et al.’ reported a reduction in operative mortality from 28% to 8% after preoperative external drainage. In that study, over a third of the patients drained did not have subsequent surgery, and the selection process is not clear. Our own overall operative mortality in patients drained preoperatively is 24%, and further study is necessary. We are now doing a randomised controlled trial of the effect of preoperative biliary drainage on operative mortality and morbidity in patients with surgical obstructive jaundice. Internal drainage with a ’Teflon’ endoprosthesis is a more recent innovation, and Pereiras et al. have described the successful use of a large-bore tube in 12 patients with unresectable malignant neoplasms.13 Our results show benefit in 6 out of 7 patients, one with a benign stricture. The prognosis in this group depends on the nature of the underlying disease, but jaundice and pruritus are relieved. Palliation is achieved without difficult and potentially fatal surgey. Internal and external transhepatic biliary drainage is an exciting advance in the management of patients with obstructive jaundice and should be considered before surgery is undertaken. The surgeon can now operate when the patient’s condition is optimum or choose drainage in place of surgery. J. S. D. is a Saltwell research fellow. Requests for reprints should be addressed to J. S. D., Department of Medicine, Royal Free Hospital, Pond Street, London NW3 2QG. REFERENCES 1.

2. 3. 4. 5.

Nakayama T, Ikeda A, Okuda K. Percutaneous transhepatic drainage of the biliary tract. Gastroenterology 1978; 74: 554-59. Feduska NJ, Dent T, Lindenauer SM. Results of palliative operations for carcinoma of the pancreas. Arch Surg 1971; 103: 330-34 Dawson JL. The incidence of post-operative renal failure in obstructive jaundice. Br J Surg 1965; 52: 663-65. Rubio C, Berger L, Dooley J, Sherlock S. Ultrasonography in the differential diagnosis of jaundice. Gut 1978; 19: A967. Taylor KJW, Rosenfield AT, Spiro HM. Diagnostic accuracy of grey scale ultrasonography for the jaundiced patient. Arch Intern Med 1979; 139: 60-63.

Nielsen M, Justesen T. Anaerobic and aerobic bacteriological studies in biliary tract disease. Scand Gastroenterol 1976; 11: 437-46. J 7. Takada T, Hanyn F, Kobayashi S, Uchida Y. Percutaneous transhepatic cholangial drainage: direct approach under fluoroscopic control. J Surg Oncol 1976; 8: 83-97.

6.

Lykkegaard

1044

RETROGRADE CEREBRAL EMBOLISM L. A. WILSON A. L. PRIOR A. K. YATES R. G. GOSLING R. W. ROSS RUSSELL

Guy’s Hospital and St. Thomas’ Hospital, London Cerebral embolism may complicate lesions of the subclavian arteries or aortic isthmus distal to the origins of the vertebral or carotid arteries. This may be due to retrograde propagation of occlusive thrombus. In other cases the vessels are patent but there are periods of reverse blood flow, creating a potential for reflux of embolic material to the ostia of the neck vessels.

Summary

Introduction CEREBRAL embolism is usually caused by disease in or neck arteries. However, it may complicate subclavian-artery disease distal to the origin of the vertebral arteries1-3 and has been suggested to arise from aortic plaques immediately distal to the origin of the left subclavian artery.4 We report here five such cases of cerebral embolism and discuss the mechanism and implications for clinical management.

the heart

Fig.

1—Dilatation and

irregularity of

artery lumen in case 1 in relation occlusion of the axillary artery.

Case-reports Case1 A left-handed managed 35, presented with a two-month history of aching discomfort in the right upper arm, exacerbated by use of that limb. He had also noted tingling in the fingers of the right hand, particularly the ring and little fingers. When exposed to cold the hand turned pale and blue and the fingertips became painful. At examination the abnormal findings were a right supraclavicular bruit, absence of right arm pulses, and coldness and discoloration of the right hand. A right cervical rib was evident at X-ray. Doppler ultra-

sound measurement of blood velocities demonstrated compression of the right subclavian artery, varying with head position, with complete block from the distal end of the axillary artery. Angiography (fig. 1) showed dilatation and irregularity of the lumen of the right subclavian artery in relation to the cervical rib and total occlusion of the axillary artery about 10 cm distally with faint filling of forearm vessels. Surgery was planned but, eleven days after initial investigation, he suddenly lost the use of his left arm and leg and his face became twisted. There was no headache, vomiting, or loss of consciousness. Examination confirmed a dense left hemiplegia. Speech, sensation, and the visual fields remained normal. Computerised tomography showed a large area of low attenuation deep in the right cerebral hemisphere in middle-

JA, Hoevels J, Simert G, Tylen U, Vang J. Clinical aspects of nonsurgical percutaneous transhepatic bile drainage in obstructive lesions of the extrahepatic bile ducts. Ann Surg 1976; 189: 58-61. 9. Ring EJ, Oleaga JA, Freiman DB, Husted JW, Lunderquist A. Therapeutic applications of catheter cholangiography. Radiology 1978; 128: 333-38. 10. Dawson JL. Jaundice and anoxic renal damage: protective effect of mannitol. Br Med J 1964; i: 810-11. 11. Bomzon L, Kew MC, Rosendorff C. The effect of phenoxybenzamine and saralasin on the altred renal blood flow associated with obstructive jaundice in baboons. Clin Exp Pharmacol Physiol 1977; 4: 365-73. 12. Bomzon L, Witton PB, McCalden A. Impaired skeletal muscle vasomotor response to infused noradrenaline in baboons with obstructive jaundice. Clin 8. Hansson

Sci Mol Med 1978; 55: 109-12. Rheingold OJ, Butson D, et al. Relief of malignant obstructive jaundice by percutaneous insertion of a permanent prosthesis in the biliary tree. Ann Intern Med 1978; 89: 589-93.

13. Pereiras V,

to

the right subclavian the cervical rib, with

cerebral-artery distribution. Doppler ultrasound now showed a striking change in the blood-velocity pattern in the proximal part of the right subclavian artery, suggesting extension of occlusion to its proximal part. At operation the right subclavian artery was found to be thrombosed to its origin, with considerable periarterial inflammation in relation to the large cervical rib. The cervical rib was excised and a right cervical sympathectomy performed. Treatment continues with anticoagulants and rehabilitation.

Case 2 A 21-year-old left-handed woman presented eight weeks after csesarean section following a sudden attack of weakness and loss of feeling in the left arm. This was associated with drooping of her left lower face, some word-finding difficulty, and impaired vision to the left with an impression of glare in the left eye. This episode lasted about four minutes and was followed by complete recovery. A year before she had had a similar attack. Examination revealed a pulsatile swelling at the base of the neck on the right, over which a loud systolic bruit was audible. Head turning to the left caused reduction or disappearance of the right arm pulse. She was normotensive, with no abnormality on cardiac or neurological examination. Plain chest X-ray revealed bilateral cervical ribs. Selective angiography showed no abnormality of either carotid artery or the left subclavian artery; there was stenosis of the right subclavian artery with dilatation in relation to the anterior end of the right cervical rib. Doppler ultrasound measurement of blood-flow velocities in the left subclavian artery showed a normal pattern and a minimal disturbance on head rotation. However, in the right subclavian artery with the head in a central position, there was a pronounced oscillation in the flow pattern proximal to the stenosis. There were three periods of reverse flow in each cardiac cycle. Further, with head rotation to the left or right there was progressive reduction in the brachial flow velocities and almost complete cessation of brachial flow when the head was rotated to the extreme left (fig. 2). Three further similar transient ischæmic attacks occurred. At operation the scalenus anterior and the fibrous band com-