Gastrointestinal
Gastrointest Radiol 3, 23-31 (1978)
Radiology
Percutaneous Transhepatic Intubation of Bile Ducts for Combined Internal-External Drainage in Preoperative and Palliative Treatment of Obstructive Jaundice J. Hoevels 1, A. Lunderquist 1, and I. Ihse 2 Departments of Diagnostic Radiology 1 and Surgery2, University Hospital, Lund, Sweden
A b s t r a c t . Percutaneous transhepatic intubation
and combined internal-external drainage of the biliary system was performed in 15 patients with occlusion of the extrahepatic bile ducts due mainly to cholangiocarcinoma, metastases of the hepatoduodenal ligament, and tumors of the periampullary region. The technique is described and the value of the procedure in temporary decompression and combined internalexternal bile drainage prior to radical surgery is demonstrated. Its advantages as a palliative method are evident in far-advanced malignancy when extensive and complicated surgical procedures are ill-advised. Key words: Obstructive jaundice - Percutaneous transhepatic intubation - Biliary decompression Preoperative drainage - Palliation.
Malignancy o f t h c cxtrahepatic bile ducts and periampullary region often remains unsuspected until very late in the course of the disease, the main s y m p t o m in most cases (60 90%) [1-3] being jaundice. Secondary spread to adjacent structures is present in about 90% [4] of the cases when the final diagnosis is made. Radical surgery in such advanced stages is not possible, whereas the establishment of permanent bile drainage is mandatory. Various surgical methods for permanent external drainage by transhepatic intubation of the bile ducts [5 8], as well as insertion of different kinds of endoprotheses [9, 10], have been described and successfully applied. Palliation in obstructive jaundice due to malignancy can be performed nonsurgically by using the diagnostic percutaneous transhepatic access to the intra- and extrahepatic bile ducts for external drainage via a solid Address reprint requests to : J. Hoevels, M.D., Department of Diagnostic Radiology, University Hospital, S-221 85 Lund, Sweden
catheter [11 13]. In order to achieve a satisfying drainage effect, the indwelling catheter has several side-holes and its tip is located as close as possible to the site of the obstruction. Operative mortality of icteric patients with malignant tumors of the biliary tract is high [4]. A marked decrease of fatal cases has been reported when appropriate measures are taken to decrease jaundice prior to radical surgery [2, 15]. In addition to surgical decompression as the first step in a two-stage operation, successful preoperative decrease of jaundice has been accomplished by nonsurgical percutaneous transhepatic intubation [11-13, 16 21]. This procedure has proved to be as effective as a surgically performed biliodigestive anastomosis. Thc disadvantage of postoperative adhesions, which may complicate scheduled radical surgery, is eliminated. Benign strictures of the extrahepatic bile ducts are often sequelae of previous surgical trauma. Subsequent surgical reconstructive intervention may result in new stricture formation which leads to more fibrosis, rendering subsequent operations extremely difficult. Hepaticojejunostomy with temporary transhepatic intubation has proved to be a successful method for re-establishing hepatodigestive bile flow, combined, when necessary, with external biliary decompression [4, 14, 22 26]. However, any kind of surgical reTable 1. Case material
Number of cases Periampullary carcinoma Cholangiocarcinoma Metastases in the porta hepatis and hepatoduodenal ligament Iatrogenic hepaticoduodenal fistula Hodgkin's disease Choledocholithiasis
0364-2356/78/0003-0023 $01.80 9 1978 Springer-Verlag New York Inc.
24
J. Hoevels et al. : Percutaneous Transhepatic Intubation
Table 2
Diagnosis
Duration of internalexternal drainage by percutaneous transhepatic intubation
Operation
Reason for drainage
1
Cancer of stomach. Metastases to liver and hepatoduodenal ligament
3 months until death
Inoperable
Extrahepatic bile stasis, palliative decompression of bile ducts
2
Cancer of stomach. Metastases to liver and porta hepatis
19 months until death
Inoperable
Extrahepatic bile stasis, palliative decompression of bile ducts
3
Cholangiocarcinoma
3 months until death
Hepaticojejunostomy
Extrahepatic bile stasis, palliative decompression of bile ducts. Recurrency in biliodigestive anastomosis
Iatrogenic hepaticoduodenal fistula, liver cirrhosis, portal hypertension, esophageal varices
16 months so far
Reconstruction of bile ducts considered too riskful because of previous subhepatic abscess + portal hypertension
Extrahepatic bile stasis, permanent palliative bile drainage planned
Cancer of colon. Metastases to liver and hepatodnodenaI ligament
3 months
Inoperable
Extrahepatic bile stasis, temporary decompression of bile ducts during regional cytostatic therapy via catheter in common hepatic artery
Cancer of colon. Metastases to liver and hepatoduodenal ligament
6 months until death
Inoperable
Extrahepatic bile stasis, palliative decompression of bile ducts
Cholangiocarcinoma Metastases to liver
3 weeks until death
Inoperable
Extrahepatic bile stasis, palliative decompression of bile ducts
Cancer of stomach. Metastases to hepatoduodenal ligament
1.5 months until death
Inoperable
Extrahepatic bile stasis, palliative decompression of bile ducts
Cancer of periampullary region
3.5 months preoperatively
Local excision of tumor + choledochojejunostomy
Extrahepatic bile stasis, preoperative decompression of bile ducts
10
Cancer of periampullary region
4 weeks preoperatively
Total pancreatectomy + choledochojejunostomy
Extrahepatic bile stasis, preoperative decompression of bile ducts
11
Choledocholithiasis with marked biliary stasis
3 months preoperatively
Choledocholithectomy performed after initial postponement because of myocardial infarction
Extrahepatic bile stasis, preoperative decompression of bile ducts
12
Cancer of periampullary region Cancer of periampullary region
3 weeks postoperatively
Total pancreatectomy
Bile leakage from hepaticojejunostomy
2 weeks postoperatively
Total pancreatectomy
Bile leakage from bed of gallbladder
14
Cancer of gallbladder with infiltration of hepatoduodenal ligament
1 month postoperatively
Resection of common bile duct + hepaticojejunostomy
Extrahepatic cholestatis because of narrow biliodigestive anastomosis
15
Hodgkin's disease, enlarged lymph nodes in hepatoduodenal ligament
1 month
Case
13
Extrahepatic bile stasis, temporary decompression of bile ducts during radiotherapy (3.270 rad applied to region of hilum of liver)
J. Hoevels et al. : Percutaneous Transhepatic Intubation c o n s t r u c t i o n o f t h e bile d u c t s is e x c l u d e d i n t h e p r e s ence of marked portal hypertension with varicose veins in the hepatoduodenal ligament. In this situation, percutaneous transhepatic catheterization of the biliary system may be the only means of creating a permanent internal-external bile fistula. A major problem in percutaneous transhepatic b i l e d r a i n a g e is d i s l o d g e m e n t o f t h e i n d w e l l i n g c a t h e ter. T h e p o s i t i o n o f t h e c a t h e t e r c a n b e s t a b i l i z e d m a r k e d l y b y p a s s i n g t h e t i p t h r o u g h t h e site o f o b struction into the distal part of the common bile duct or into the duodenum [12, 13]. M u l t i p l e s i d e h o l e s p r o x i m a l l y as w e l l as d i s t a l l y t o t h e o b s t r u c t i o n p e r m i t i n t e r n a l bile d r a i n a g e , w h i l e t h e p o s s i b i l i t y is g i v e n for external bile drainage, if necessary. Our experience w i t h t h i s t e c h n i q u e is b a s e d o n 15 c a s e s o f b i l i a r y obstruction with various origins.
25
Table 3 Case
Total volume of bile drained externally during 24 h
Bilirubin serum level during period of drainage (normal range/SI-units a 3-20 gmol/liter)
Complications
1
400 ml--,300 ml
435~ 140 gmol/liter
Dislodgement of catheter twice
2
600 ml-~ 70 ml
100-,
Occlusion of catheter three times
3
500 ml-.100 ml
150-,
Gastrointest Radiol 3, 23-31 (1978)
Radiology
Percutaneous Transhepatic Intubation of Bile Ducts for Combined Internal-External Drainage in Preoperative and Palliative Treatment of Obstructive Jaundice J. Hoevels 1, A. Lunderquist 1, and I. Ihse 2 Departments of Diagnostic Radiology 1 and Surgery2, University Hospital, Lund, Sweden
A b s t r a c t . Percutaneous transhepatic intubation
and combined internal-external drainage of the biliary system was performed in 15 patients with occlusion of the extrahepatic bile ducts due mainly to cholangiocarcinoma, metastases of the hepatoduodenal ligament, and tumors of the periampullary region. The technique is described and the value of the procedure in temporary decompression and combined internalexternal bile drainage prior to radical surgery is demonstrated. Its advantages as a palliative method are evident in far-advanced malignancy when extensive and complicated surgical procedures are ill-advised. Key words: Obstructive jaundice - Percutaneous transhepatic intubation - Biliary decompression Preoperative drainage - Palliation.
Malignancy o f t h c cxtrahepatic bile ducts and periampullary region often remains unsuspected until very late in the course of the disease, the main s y m p t o m in most cases (60 90%) [1-3] being jaundice. Secondary spread to adjacent structures is present in about 90% [4] of the cases when the final diagnosis is made. Radical surgery in such advanced stages is not possible, whereas the establishment of permanent bile drainage is mandatory. Various surgical methods for permanent external drainage by transhepatic intubation of the bile ducts [5 8], as well as insertion of different kinds of endoprotheses [9, 10], have been described and successfully applied. Palliation in obstructive jaundice due to malignancy can be performed nonsurgically by using the diagnostic percutaneous transhepatic access to the intra- and extrahepatic bile ducts for external drainage via a solid Address reprint requests to : J. Hoevels, M.D., Department of Diagnostic Radiology, University Hospital, S-221 85 Lund, Sweden
catheter [11 13]. In order to achieve a satisfying drainage effect, the indwelling catheter has several side-holes and its tip is located as close as possible to the site of the obstruction. Operative mortality of icteric patients with malignant tumors of the biliary tract is high [4]. A marked decrease of fatal cases has been reported when appropriate measures are taken to decrease jaundice prior to radical surgery [2, 15]. In addition to surgical decompression as the first step in a two-stage operation, successful preoperative decrease of jaundice has been accomplished by nonsurgical percutaneous transhepatic intubation [11-13, 16 21]. This procedure has proved to be as effective as a surgically performed biliodigestive anastomosis. Thc disadvantage of postoperative adhesions, which may complicate scheduled radical surgery, is eliminated. Benign strictures of the extrahepatic bile ducts are often sequelae of previous surgical trauma. Subsequent surgical reconstructive intervention may result in new stricture formation which leads to more fibrosis, rendering subsequent operations extremely difficult. Hepaticojejunostomy with temporary transhepatic intubation has proved to be a successful method for re-establishing hepatodigestive bile flow, combined, when necessary, with external biliary decompression [4, 14, 22 26]. However, any kind of surgical reTable 1. Case material
Number of cases Periampullary carcinoma Cholangiocarcinoma Metastases in the porta hepatis and hepatoduodenal ligament Iatrogenic hepaticoduodenal fistula Hodgkin's disease Choledocholithiasis
0364-2356/78/0003-0023 $01.80 9 1978 Springer-Verlag New York Inc.
24
J. Hoevels et al. : Percutaneous Transhepatic Intubation
Table 2
Diagnosis
Duration of internalexternal drainage by percutaneous transhepatic intubation
Operation
Reason for drainage
1
Cancer of stomach. Metastases to liver and hepatoduodenal ligament
3 months until death
Inoperable
Extrahepatic bile stasis, palliative decompression of bile ducts
2
Cancer of stomach. Metastases to liver and porta hepatis
19 months until death
Inoperable
Extrahepatic bile stasis, palliative decompression of bile ducts
3
Cholangiocarcinoma
3 months until death
Hepaticojejunostomy
Extrahepatic bile stasis, palliative decompression of bile ducts. Recurrency in biliodigestive anastomosis
Iatrogenic hepaticoduodenal fistula, liver cirrhosis, portal hypertension, esophageal varices
16 months so far
Reconstruction of bile ducts considered too riskful because of previous subhepatic abscess + portal hypertension
Extrahepatic bile stasis, permanent palliative bile drainage planned
Cancer of colon. Metastases to liver and hepatodnodenaI ligament
3 months
Inoperable
Extrahepatic bile stasis, temporary decompression of bile ducts during regional cytostatic therapy via catheter in common hepatic artery
Cancer of colon. Metastases to liver and hepatoduodenal ligament
6 months until death
Inoperable
Extrahepatic bile stasis, palliative decompression of bile ducts
Cholangiocarcinoma Metastases to liver
3 weeks until death
Inoperable
Extrahepatic bile stasis, palliative decompression of bile ducts
Cancer of stomach. Metastases to hepatoduodenal ligament
1.5 months until death
Inoperable
Extrahepatic bile stasis, palliative decompression of bile ducts
Cancer of periampullary region
3.5 months preoperatively
Local excision of tumor + choledochojejunostomy
Extrahepatic bile stasis, preoperative decompression of bile ducts
10
Cancer of periampullary region
4 weeks preoperatively
Total pancreatectomy + choledochojejunostomy
Extrahepatic bile stasis, preoperative decompression of bile ducts
11
Choledocholithiasis with marked biliary stasis
3 months preoperatively
Choledocholithectomy performed after initial postponement because of myocardial infarction
Extrahepatic bile stasis, preoperative decompression of bile ducts
12
Cancer of periampullary region Cancer of periampullary region
3 weeks postoperatively
Total pancreatectomy
Bile leakage from hepaticojejunostomy
2 weeks postoperatively
Total pancreatectomy
Bile leakage from bed of gallbladder
14
Cancer of gallbladder with infiltration of hepatoduodenal ligament
1 month postoperatively
Resection of common bile duct + hepaticojejunostomy
Extrahepatic cholestatis because of narrow biliodigestive anastomosis
15
Hodgkin's disease, enlarged lymph nodes in hepatoduodenal ligament
1 month
Case
13
Extrahepatic bile stasis, temporary decompression of bile ducts during radiotherapy (3.270 rad applied to region of hilum of liver)
J. Hoevels et al. : Percutaneous Transhepatic Intubation c o n s t r u c t i o n o f t h e bile d u c t s is e x c l u d e d i n t h e p r e s ence of marked portal hypertension with varicose veins in the hepatoduodenal ligament. In this situation, percutaneous transhepatic catheterization of the biliary system may be the only means of creating a permanent internal-external bile fistula. A major problem in percutaneous transhepatic b i l e d r a i n a g e is d i s l o d g e m e n t o f t h e i n d w e l l i n g c a t h e ter. T h e p o s i t i o n o f t h e c a t h e t e r c a n b e s t a b i l i z e d m a r k e d l y b y p a s s i n g t h e t i p t h r o u g h t h e site o f o b struction into the distal part of the common bile duct or into the duodenum [12, 13]. M u l t i p l e s i d e h o l e s p r o x i m a l l y as w e l l as d i s t a l l y t o t h e o b s t r u c t i o n p e r m i t i n t e r n a l bile d r a i n a g e , w h i l e t h e p o s s i b i l i t y is g i v e n for external bile drainage, if necessary. Our experience w i t h t h i s t e c h n i q u e is b a s e d o n 15 c a s e s o f b i l i a r y obstruction with various origins.
25
Table 3 Case
Total volume of bile drained externally during 24 h
Bilirubin serum level during period of drainage (normal range/SI-units a 3-20 gmol/liter)
Complications
1
400 ml--,300 ml
435~ 140 gmol/liter
Dislodgement of catheter twice
2
600 ml-~ 70 ml
100-,
Occlusion of catheter three times
3
500 ml-.100 ml
150-,
