Transhepatic Cholangiography Esmond M. Mapp, MD Philadelphia, Pennsylvania

Transhepatic cholangiograms were done on 81 patients. The Teflon sheath needle was used for 71 cases and the "Chiba" needle for ten. The "Chiba" needle transhepatic cholangiogram is recommended for the study of jaundiced patients with biliary duct dilatation, which is detected by ultrasound or computerized axial tomography.

Since 1965 we have performed transhepatic cholangiograms on 81 patients. The 18-gauge Teflon sheath assembly was used in the first 71 cases and the final form of the technique was an anterior subcostal approach, with slow catheter withdrawal and repeated injections of small amounts of contrast material.' With meticulous attention to detail, we found the technique safe enough that we eventually felt it was no longer mandatory to perform the study on the morning surgery was planned. On one occasion the surgeon reported finding about

Presented at NMA Scientific Assembly, 1975, Miami Beach, Florida and revised for publication. From the Department of Radiology, Episcopal Hospital, Philadelphia, Pa. Requests for reprints should be addressed to Dr. Esmond M. Mapp, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa 19107.

300 cc of blood in the peritoneal cavity. There were no instances of bile peritonitis. Frequently, the surgeon could not identify the needle puncture site in the liver. The "Chiba" needle,2 a thin walled flexible steel needle 15 cm in length, 0.7 mm in outer diameter and with a 30-degree bevel angle, was used in the last ten patients. With this needle, we have used the lateral approach in the tenth or ninth intercostal space, directing the needle towards the twelfth thoracic vertebral body. This approach is altered when necessary to accommodate variations in body habitus such as obesity or conditions such as severe emphysema. As the needle is slowly withdrawn under fluoroscopic control, small amounts of contrast material are injected until bile duct filling is recognized. Fewer punctures of the liver have been necessary to obtain opacification of the biliary ducts. Ducts were located on either


the first or second puncture in both dilated (Figures 1-3) and non-dilated systems (Figure 4). Since it is difficult and sometimes impossible to aspirate bile with the "skinny" needle, a bacteremia is the most significant potential complication. Therefore, antibiotic coverage is recommended, and excessive amounts of contrast should be avoided. If there is biliary obstruction when bile duct filling is obtained, it is essential that the patient be placed in the erect or semi-erect position. This allows the contrast to flow to the point of obstruction and prevents misdiagnosis of the level of obstruction. Fluoroscopic and overhead films are obtained, the needle being removed prior to the overhead ones. Expiration chest film is obtained to exclude the possibility of pneumothorax. Early surgical decompression is advisable when complete obstruction of the biliary system is demonstrated. In the initial enthusiasm for new 293



Figure 1. Multiple gallstones in gallbladder and dilated common duct in a 29-year-old male patient who has obstructive jaundice.

Figure 3. Obstructed common duct due to carcinoma of the head of the pancreas.



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Figure 2. Multiple common duct stones in an 82-year-old male patient who has obstructive jaundice.

"glamorous" techniques like endoscopic retrograde cholangiopancreatography (ERCP). certain fundamentals were ignored and some patients with suspected ductal obstruction were referred for that test. If a complete obstruction was found, the surgeon still did not know whether he could complete an anastomosis because he had not seen the "businessend" of the duct and had to resort to the old technique of transhepatic cholangiography to get the complete information. In other instances ERCP 294


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common duct with Figue*4.Normal obstruction in patient suspected



having biliary obstruction.

was found to be technically unfeasible. Currently the jaundiced patient is screened by ultrasound to determine whether the biliary ducts are dilated. Then patients without ductal dilatation are referred for ERCP and those with it are examined by transhepatic cholangiography. Because of the much shorter time and lower cost involved transhepatic cholangiography is the procedure of choice for use on patients with ductal dilatation. It is also indicated in liver disease where the laboratory and clinical data are incon-

clusive and ultrasound and computerized tomography are not available for screening.

Literature Cited 1. Herba MJ, Kiss J: Percutaneous transhepatic cholangiography. J Can Assoc Radiol 22:22-29, 1971 2. Okuda K, Tanikawa K, Emura T, et al: Non-surgical percutaneous transhepatic cholangiography -diagnostic significance in medical problems of the liver. Am J Dig Dis 19:21-36. 1974


Transhepatic cholangiography.

Transhepatic Cholangiography Esmond M. Mapp, MD Philadelphia, Pennsylvania Transhepatic cholangiograms were done on 81 patients. The Teflon sheath ne...
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