Interventional Eric vanSonnenberg, Oliver G. Esch, MD

MD #{149}Horacio B. D’Agostino, MD Robert L. Sanchez, David E. Easter, MD #{149}Barbara B. Gosink, MD

The authors describe their initiab expenence with a dedicated intraluminab ultrasound (US) device that was coupled to a catheter and introduced percutaneously into the gallbladder and/or bile ducts. Access was created with interventional radiobogic techin 22 patients

and

at laparos-

E

expenences with intravascubar ultrasound (US) (1-4) and surgical access for US in the genitouriARLY

nary

system

(5) suggest

that

valuable

information may be obtained with use of endoluminal probes. Intraluminal vascular US has shown clot, wall abnormabities,

and

patency

or clogging

of filters (6). One in vitro report provided data on the appearance of and the size criteria for various nonvascubar structures in the body (7).

seen

high-resolution internal transducers within body tubes and organs may yield information beyond that avail-

bile

duct

and

gallblad-

der debris, stones, ductal strictures, and tumors. Additional information provided with this technique over other diagnostic studies included differentiation of intrabuminal filling defects, examination of areas inaccessible

to conventional

observations

imaging,

about

the walls

and

of the

ducts and gallbladder. Percutaneous US examination of metallic stents

within the bile ducts and of fibbing defects in the ducts at laparoscopic chobecystectomy was of particular interest and altered subsequent therapy.

The

procedure

is simple,

straightforward, and devoid of cornplications. While refinements and improvements are needed, this diagnostic technique holds promise. Index Bile

terms:

Bile ducts,

ducts,

76.1298 technology Gallbladder, technology

prostheses,

Catheters a

neoplasms,

76.461

Bile

#{149}

76.30 ducts,

US,

and catheterization,

#{149}

Gallbladder, US, 762.1298

calcium, 76.289 Ultrasound (US),

#{149}

It is hypothesized

able

with

In this

other

report,

experience

that

use

diagnostic

methods.

we describe with

of such

our

a US unit

AND

duct tract

in five patients. was percutaneous

1992;

METHODS

Access to the in 27 exami-

nations (22 patients) and by means of laparoscopic chobecystectomy in four patients. Five patients underwent more than Percutaneous been created

182:693-696

patients),

From

the

Departments

of Radiology

(E.V.,

H.B.D., R.L.S., B.B. Goodacre, B.B. Gosink), Mcdicine (E.V., O.G.E.), and Surgery (DEE.), University of California San Diego Medical Center, 225 Dickinson St. San Diego, CA 92103. Received July 11, 1991; revision requested August 23; revision received September 30; accepted October 3. Address reprint requests to E.V. RSNA, 1992

radiographic tracts had previously to treat stones (17

tumors

(three

patients),

or stric-

tures (with associated stones) (two patients). Nine patients were undergoing gallstone dissolution with methyl tert-butyl ether (MTBE), six patients were undergoing percutaneous extraction of gallstones, four patients were undergoing therapy for bile duct stones, three patients with obstructive jaundice were undergoing tients

percutaneous were

drainage, undergoing

and laparoscopic

four

as an

adjunctive

guidance and

control.

cholangiography

were used routinely for diagnosis and to guide therapeutic maneuvers. Conventional US was performed in each patient as well. All procedures were performed in the radiology department except in the laparoscopic cholecystectomy cases, in

which

procedures

were

performed

in an

room.

The US unit was manufactured sonics 20-MHz

(Milpitas,

Calif).

by Dia-

A rotating

radial

transducer was used. The transducer was at the terminus of a metallic shaft and was housed and bathed in saline for coupling. The shaft was inserted into the guiding catheter (Fig I). The catheter was

6 F and

of two

types:

either

with

or

without the capability to be inserted over a guide wire (up to 0.025 inch) (Meditech/Boston Scientific, Watertown, Mass).

Over a period of 1 year, 31 examinations were carried out in 26 patients (eight men and 18 women) who ranged in age from 39 to 84 years. All studies were performed via percutaneous tracts. The gallbladder was examined in 22 patients, the intrahepatic bile ducts in six patients, the extrahepatic bile ducts in seven patients, and the cystic biliary

served

Cholecystography

initial

introduced

percutaneously into the gallbladder and bile ducts in 26 patients. The technique, results, utility, and issues for future development form the basis of this article.

MATERIALS

lecystectomy. No tract was established exclusively to perform percutaneous US. Two patients with strictures had undergone percutaneous placement of metallic stents that were examined internally within the bile ducts (one at 10 days, the other at 5 weeks). For the radiobogic percutaneous access cases, simultaneous fluoroscopy after injection of contrast material

operating

one study. Radiology

MD

B. Goodacre,

US Ducts’

copy in four patients. Thirty-one ex.aminations in 26 patients revealed information on normal anatomy, pathologic processes, and responses to therapy. The pathologic processes included

#{149} Brian

#{149}

Percutaneous Intraluminal in the Gallbladder and Bile

niques

MD

Radiology

The depth

of penetration

of the ultra-

sound beam was up to approximately 2 cm. The technique for percutaneous US is to insert an 8-F or larger sheath over a guide wire through the percutaneous tract, directly into the bile duct or gallbladder. A safety guide wire is placed within the ducts or gallbladder to maintain access. The percutaneous US catheter is inserted, and its position is monitored both with US

and by means oroscopy rial. The guide

wire

of periodic

checks

with

after injection of contrast catheter was inserted over routinely

rate positioning

to help

ensure

of the transducer

flu-

matea accu-

(Fig 2).

At laparoscopic cholecystectomy, the percutaneous US catheter loaded with the transducer was inserted through a trocar in the right upper quadrant; the catheter was positioned in the cystic duct through a small slit and was maneuvered down the

pa-

Abbreviation:

cho-

ether.

MTBE

=

methyl

tert-butyl

693

1.

2.

Figures

1, 2.

transducer serted into

(1) Catheter and 20-MHz transducer tip is at the clear end of the catheter the bile ducts over a guide wire and

bile

with

ducts

laparoscopic

visual

ready (arrow). through

for use. Note the back end of the metallic transducer shaft within the sheath. The (2) Technique of percutaneous US examination. Percutaneous US catheter is being a peel-away sheath. A 7-F irrigation catheter protrudes from the sheath.

in-

guid-

ance.

RESULTS Images were obtained in all patients when the

the

machine

were

successfully mechanics

in order

of

(26 of 31

cases). No technical problems occurred with catheter passage. There was no perforation or bleeding due to the procedure. Five procedures were terminated prematurely because of machine malfunction; in these cases, there was inability to generate a recognizable image. Six procedures were

continued mittent

loss

despite

varying

artifacts.

Problems

of contrast,

inability machinery esthesia cautery

speckled

to sustain in the monitoring instruments,

and

inter-

included

artifacts,

or

an image. Other room including andevices, lasers, and other elec-

Figure

3.

Scan

obtained

from

percutaneous

US performed through percutaneous cholecystostomy tract. Arrows point to highly echogenic guide wire and gallstone (12o’clock position) and less echogenic gallbladder (GB) wall.

strating a stone in the cystic duct (arrows). This area was not visualized on a catheter cholangiogram. The transducer is in the com-

as moderately

General observations guide wires were sharply

were that echogenic,

Observations in the bile ducts included the appearance of normal anatomy, thickened bile ducts, strictures, tumors, debris, and stones. Anatomic display of the major bile ducts

that

catheters

echogenic

(Fig 5), the confluence

(less

so than

trical devices the artifacts.

probably

also guide

contributed

were wires),

and

to

that

a

turbulent appearance of fluid was seen on injection of saline or contrast material. Specific observations included visualization of stones in the gallbladder (15 patients) (Fig 3) or in the bile ducts (intrahepatic, two patients; extrahepatic, three patients; cystic duct, two patients). Debris was observed in the bile ducts, the gallbladder, and the cystic duct (Fig 4) and within one metallic stent. The

fragments measured as small as 1-2 mm. Tumor was visualized in the intra- and extrahepatic patients. No adjacent were identified with 694

Radiology

bile ducts in two lymph nodes certainty.

right tion mon

biliary

between

the

and left hepatic ducts, the juncof the cystic duct with the comduct, and first-order intrahepatic

radicles

was

observed.

Normal

ducts had a discrete, 1-2-mm echogenic wall. Portal vein branches and the hepatic artery were noted in their characteristic locations. Wall thickening was seen with sclerosing cholangitis (one patient) (Fig 6) and with benign strictures (two patients). Distortion of normal ductal architecture was observed with intrahepatic bile duct tumor (several ducts in two patients) (Fig 7). Stones appeared as

highly acoustic

echogenic shadowing.

foci with Debris

radial was

noted

mon

duct.

echogenic

material

without posterior shadowing. Evaluation of metallic biliary

revealed patient other selves small nicity

a normal

stents

in one

and stones and debris in anpatient (Fig 8). The stents themwere quite echogenic, with a posterior shadow. The echogeof the stent was mostly in a cir-

cumferential stent

appearance

was

pattern. flattened

However, and

distorted

one by

an adjacent periductab tumor. In the gallbladder, observations included stones, debris, and gallbladder wall thickness and integrity. Stones were noted to be echogenic, with shadowing. In two patients, the gallbladder wall was studied before and after infusion of MTBE; in one patient, the wall thickened by 2 mm (from 2 to 4 mm); the other patient showed no change. Debris that was observed during dissolution therapy

March

1992

main right and left hepatic duct confluences, and the cystic duct entrance into the common duct. Portal vein branches and the hepatic artery were well seen in their characteristic positions adjacent to the bile ducts. With tumor and stricture, the ductal and gallbladder walls were thickened or normal architecture was obliterated.

Nodularity

and

eccentricity

were

seen

with tumor. Stones were differentiated from bubbles, debris, and clot by means of characteristic sonographic signs of echogenicity and clean shadFigure

5.

example

Percutaneous

of confluence

US scan

(arrow)

and left hepatic bile ducts. within the ducts.

owing. Percutaneous US might be used to help define response to various types of therapy within the gallbladder and bile ducts. Tumor shrinkage or growth is an obvious possibility, such

showing

of main right

There

is debris 7. Percutaneous US scan showing Klatskin tumor extending in right hepatic duct (RHD). Arrows point to nodular softtissue masses irregularly protruding in right hepatic duct. Coiled guide wire is seen at 6-o’clock position. Figure

taneous

tient.

US

The

examination

studies

in any

usually

lasted

as with sponse

pa-

15-20

minutes.

Preliminary observations suggest that the technique of percutaneous US is safe and rapid and may offer complementary or supplemental inFigure 6. Percutaneous thick wall of common a patient

with

sclerosing

US scan showing hepatic duct (CHD) cholangitis.

duct wall appears inhomogeneous ened in an asymmetric pattern. noted at 3-4-o’clock position.

was

less

tenor

echogenic

in bile

and thickGuide wire is

without

a pos-

shadow.

also received material into

who

underwent US examination

radio-

injections of contrast the gallbladder or bile

Compared injection

percutaneous

with fluoroscopy of contrast material,

US offered

the

follow-

information: (a) gallthickening, (b) differentiation of stone from debris or clot within a metallic stent, (c) appearance of the bile duct wall in the patients

ing additional bladder wall

with duct

early experience, additional information was provided with use of percutaneous US to differentiate bile duct stone from blood clot or debris, to visualize stones and debris in intrahepatic ducts or the cystic duct when injection of contrast material into the common duct did not opacify these

ducts,

The patients logic percutaneous

ducts. after

and

The

formation beyond that of available clinical and radiobogic studies. In this

sclerosing cholangitis tumor, (d) presence

and

bile

of cystic duct stones (when the duct was not seen fluoroscopicabby), and (e) demonstration and differentiation of stones in the common duct from debris and air

bubbles at baparoscopic tomy (Fig 9).

cholecystec-

There comfort,

were no complications, or pain caused by the

Volume

182

#{149} Number

3

dispercu-

and

to see extension

and bile duct fluoroscopically

mucosa rosing

thickening visualized

in cholangiocarcinoma, chobangitis, and bile

ture. The technique is straightforward, access into the

der

of tumor beyond lumen

is established.

duct

guide

wire.

scbestric-

bile

percutaneous once the typical ducts or gablblad-

Theoretically,

We prefer catheter, inherent

the

US

any or scope amenable sheath can be over a

latter

to

since the capability

were both anatomic Normal anatomy inof branching ducts, including the

for

in the gallbladder

and

bile

duct walls. We performed percutaneous US after the infusion of MTBE to determine the effect on the gablbladder wall. Follow-up studies showed a change in wall thickness in one patient; these changes were probably due to reversible inflammation from the solvent (8). Percutaneous US also shows the presence or absence of residual gallbladder or bile duct stone fragments, comparably or supplementally to extracorporeal US or to cholangiography; high-resolution percutaneous US demonstrates fragments as small as 1-2 mm. Patency or clogging of bile duct stents and the nature of the internal material can be assessed; visualization of these findings was superior to that with conventional US.

Current for

percutaneous catheter tract that admits a 6-F catheter is to percutaneous US. Once a has been inserted, the catheter introduced either directly or better direct the catheter has no deflection. Observations and pathologic. cluded visualization large and small

the and

Restructures

adjacent to the bile duct such as lymph nodes, the liver, and the pancreas might be even better assessed with deeper-penetrating but still high-resolution transducers. Percutaneous US may also help determine the safety of MTBE or other

solvents

DISCUSSION

cholangiocarcinoma. to therapy of those

limitations

should

provoke

future refinements. The further depth of penetration afforded by lowermegahertz transducers should permit more accurate assessment of tumor penetration; we are currently evaluating prototype 12.5-MHz transducers for this purpose. Similarly, a smaller catheter would permit the use of percutaneous US in small orifices such as tiny bile ducts, fallopian tubes, or renab calices. The portable nature of US equipment should permit expanded use of intraoperative percutaneous US, along the lines of conventional intraoperative US. Finally, percutaneous US might be perfectly suitable for three-dimensional rather than uni-

Radiology

#{149} 695

a.

b.

Figure

8. Percutaneous US demonstration of stone within metallic stent. The patient was an elderly woman who had a postcholecystectomy bile duct stricture that recurred after previous percutaneous balloon dilation. (a) Spot radiograph with catheter through right hepatic duct shows transducer within midportion of the stent. (b) At percutaneous US, echogenic focus (arrow) with shadowing is clearly visualized within the metallic stent.

planar imaging. gists, as imagers, their

primary

suits.

Undoubtedly radioboshould maintain robe

in these

3.

pur-

U

4.

Acknowledgments: Our appreciation to Robert Arcangeli for technical advice; to Holly Lloyd, RT, RDMS, and Michael Bauman, RT, for technical assistance; and to Peggy Chambers for preparation of the manuscript. 5.

References 1.

2.

Crowley RJ, von Behren PL, Couvillon LA Jr, Mai DE, Abele JE. Optimized ultrasound imaging catheters for use in the vascular system. Int J Cardiol Imaging 1989; 4: 145-151. Meyer CR, Chiang EH, Fechner KP, Fitting DW, Williams DM, Buda AJ. Feasibility of high-resolution, intravascular ultrasonic imaging catheters. Radiology 1988; 168:113116.

6.

7.

8.

IsnerJM, Rosenfield K, Losordo DW, et al. Percutaneous intravascular US as adjunct to catheter-based interventions: preliminary experience in patients with peripheral vascular disease. Radiology 1990; 175:61-70. Engeler CE, Yedlicka JW, Letourneau JG, Castaneda-Zuniga WR, Hunter DW, Amplatz K. Intravascular sonography in the detection of arteriosclerosis and evaluation of vascular interventional procedures. AJR 1991; 156:1087-1090. Goldberg BB, Bagley D, Liu JB, Merton DA, Alexander A, Kurtz AB. Endoluminal sonography of the urinary tract: preliminary observations. AJR 1991; 156:99-103. McCowan TC, Ferris EJ, Carver DK. Infenor vena caval filter thrombi: evaluation with intravascular US. Radiology 1990; 177: 783-788. Goldberg BB, Liu JB, Merton DA, Kurtz AB. Endoluminal US: experiments with nonvascular uses in animals. Radiology 1990; 175: 39-43. vanSonnenberg E, Zakko 5, Hofmann AF, al. Human gallbladder morphology after gallstone dissolution with methyl-tert-butyl ether. Gastroenterology 1991; 100:17181723.

a. .I-

___

.

1

‘

b. Figure 9. Percutaneous US at laparoscopic cholecystectomy helps define nature of filling defect. (a) Intraoperative cholangiogram demonstrates filling defect (arrow) in the distal common duct. It was uncertain whether this

was

a stone,

debris,

or an air bubble.

0 ) Percutaneous tic features bile duct.

696

#{149} Radiology

US scan shows characterisof stone (arrow). CBD = common

March

1992