Percutaneous transhepatic cholangiography

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Percutaneous transhepatic cholangiography. The bile duct catheter comes from the right (left edge of the picture) and lies with a loop in front of the tumor stenosis of the bile duct.

The percutaneous transhepatic cholangiography ( PTC ) is an interventional procedure in which by means of a thin hollow needle under fluoroscopic control percutaneously (through the skin) by puncture of the liver x-ray contrast agent in the biliary tree is introduced.

In addition, it is possible to use this access to drain the bile to the outside via a drainage (percutaneous transhepatic cholangiodrainage, PTCD or also percutaneous transhepatic drainage, PTD ) in order to eliminate a backlog in the biliary tract.

introduction

Various benign or malignant diseases of the bile duct system or the liver can lead to a build-up of bile ( cholestasis ) with the clinical picture of jaundice (jaundice). Today, the underlying disease (e.g. a concrement in the common draining bile duct) can often be detected (e.g. by means of MRI including MRCP ) . The therapy of biliary drainage problems is not possible by means of sectional imaging, and neither is a biopsy for a histological (tissue) examination. In addition, due to the magnetic effect, an MRI must not be performed on all patients. Therefore, if therapy or biopsy is required, endoscopic bile duct imaging with contrast agent injection (ERCP) and intervention is usually carried out . Since endoscopic access to the bile duct from the duodenum is not always possible, for example in the case of tumor-related narrowing or after gastric surgery, PTC serves as a reserve procedure.

The PTC is a direct cholangiography, in which a representation of the biliary tract inside and outside the liver is possible. It is important to know that the two main bile ducts draining the liver (the larger right and the smaller left) unite in the so-called hepatic bifurcation and the bile is drained from the liver via the common bile duct (the ductus hepatocholedochus ) into the duodenum . The representation of the bile ducts in the PTC and ERCP continues to be the gold standard compared to MRI / MRCP and CT.

As a rule, a PTC / PTCD is used for two different groups of symptoms:

  • Cholestasis (build-up of the bile duct system through e.g. concretions in the bile duct system or inflammatory or tumorous changes in the bile duct system), which the ERCP cannot access.
  • Leak in the biliary tract

Indications

1.Benign causes of biliary build-up:

2. Malignant causes of biliary build-up:

3. Causes of leaks in the bile duct system:

  • Leakage after Whipple's operation due to carcinoma of the pancreatic head
  • Leakage after major liver surgery (formation of a so-called bile fistula)
  • Leaks after a liver transplant

Treatment of biliary stenosis with stents

When the bile duct system is occluded by cholangiocellular tumors, pancreatic and gallbladder carcinomas or metastases located in the hilum of the liver, only 10–20% of patients can be cured by surgical means. A drainage of the bile leads to the regression of the jaundice and thus to an improvement in the associated pruritus and the inflammatory changes. Metal endoprostheses (stents) were first used in humans at the end of the 1980s, initially in vessels by Palmaz, but soon afterwards also in the bile duct system, including by Lammer and Gillams in 1990. A number of randomized studies have now shown that biliary stents in the Treatment of malignant obstructive jaundice can help improve quality of life.

The two branches of the hepatic nerve and the DHC can be kept open both with plastic prostheses and with metallic endoprostheses (stents). The patency rate of metallic stents is superior to plastic prostheses (i.e. they stay open longer and require fewer re-interventions). Covered metal stents (covered with a plastic membrane) are, in turn, superior to uncoated metal stents in terms of the patency rate. In addition to technical problems (higher risk of perforation of self-expanding stents, high rate of dislocation of covered stent grafts from the DHC into the intestine, more difficult intervention when closing a metal stent, higher risk in subsequent operations when an electrical hemostasis is to be performed), there are also cost problems.

If only the draining bile duct (DHC) has to be stenosed and supplied, it can be supplied permanently via the access route of the PTC / PTCD using a self-expanding stent. If, on the other hand, there is a (tumor-related) occlusion not only of the DHC but also of the two hepatic branches (and thus a problem with the bile outflow from both liver lobes), PTC / PTCD should be performed on both sides. Subsequently, a "reconstruction" of the hepatic fork and splinting of the common DHC should be attempted by means of two stents (advanced in parallel through both bile ducts into the DHC). A sole stent of only one branch of the hepatic nerve (usually from the right, since the right lobe of the liver is larger than the left) is only possible if the expected survival of the patient is very short and the left liver is very small. Stents that are introduced on both sides improve survival compared to only one-sided stent.

Percutaneous transhepatic cholangiodrainage (PTCD)

In the case of a stenosis or a complete occlusion of a bile duct, it is possible to use this puncture route to drain the bile to the outside through the skin via a drainage (plastic tube with several lateral holes) (percutaneous transhepatic cholangiography and drainage, PTCD) . The bile is then collected in a small plastic bag. This allows the bile to drain away and the damming up of the biliary tract is reduced. Such external drainage impairs the quality of life (drainage must be changed every 4–6 weeks; showering or swimming with the drainage directed to the outside is difficult). Therefore one tries, if possible, to insert a metallic bile duct prosthesis (stent). Depending on the underlying disease, the stents can enable the internal drainage of bile for many months without an external drain.

Complications

The typical complication of PTC / PTCD is bleeding into the bile duct system (especially in the case of malignant biliary tract disease), both when advancing the bile duct drainage and when re-dilating the access before inserting a stent. Such bleeding usually arises from a venous or portal venous vessel and can be adequately treated by inserting and leaving a large-volume drainage. Another complication are fistula connections between the biliary tract and hepatic vessels. Fistulas to the hepatic veins and portal veins can be treated with irrigation. Arteriobiliary fistulas (i.e. a puncture-related connection of the bile duct system with the hepatic artery), on the other hand, are potentially life-threatening and must be treated quickly with interventional embolization. Abscesses and superinfected hematomas (from the puncture) are also rare but dangerous complications.

Alternatives

Endoscopic retrograde cholangiopancreatography (ERCP)

The percutaneous PTC / PTCD access is more suitable than the ERCP if a high-grade bile duct stenosis has occurred due to tumor or inflammation, which has become impassable for the ERCP probe. Access to the biliary tract via its confluence with the duodenum with the help of an endoscope revolutionized the treatment of biliary tract disorders (e.g. biliary tract stones or biliary flow disorders in benign and malignant constrictions) around 30 years ago. With the help of the endoscope and a thin catheter, contrast agent is injected under X-ray control for imaging and then minimally invasive treatments (e.g. stone removal, insertion of biliary drainage) are carried out with various instruments. This procedure is called endoscopic retrograde cholangiopancreatography (ERCP) . After papillotomy, modern metal mesh prostheses can also be advanced through the endoscope up into the hilus and placed. Endoscopic duct diversions after previous operations (status after Whipplescher operation, B II gastric resection or after creating a biliodigestive anastomosis) or in the case of hilar obstructions and hepatic fork tumors are only possible to a limited extent or not.

Magnetic resonance imaging

A disadvantage of PTC or PTCD is the high radiation exposure with fluoroscopic control. On the other hand, open MRI offers the option of percutaneously displaying bile ducts free of x- rays and puncturing them with a catheter. However, this method is still not widely used and only available to a very limited extent. Furthermore, not all PTC / PTCD materials and the metal stents are MRI-compatible because they are attracted by the strong magnetic field.

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  1. ^ F. Prat, O. Chapat, B. Ducot: Predictive factors for survival of patients with inoperable malignant distal biliary strictures: a practical management guideline. In: Good . 42, 1998, pp. 76-80.
  2. ↑ JC Palmaz, OJ Garcia, RA Schatz: Placement of balloon-expandable intraluminal stents in iliac arteries: first 171 procedures. In: Radiology. 174, 1990, pp. 969-975.
  3. ↑ J. Lammer, GE Klein, R. Kleinert, K. Hausegger, R. Einlayers: Obstructive jaundice: use of expandable metal endoprosthesis for biliary drainage. Work in progress. In: Radiology. 177, 1990, pp. 789-792.
  4. ↑ A. Gillams, R. Dick, JS Dooley, H. Wallsten, A. el-Din: Self-expandable stainless steel braided endoprosthesis for biliary strictures. In: Radiology. 174, 1990, pp. 137-140.
  5. ↑ W. Luman, A. Cull, KR Palmer: Quality of life in patients stented for malignant biliary obstructions. In: Eur J Gastroenterol Hepatol. 9, 1997, pp. 481-484.
  6. ^ KA Hausegger, C. Kugler: Treatment of malignant and benign biliary obstructions with metal stents. In: Roefo. 172, 2000, pp. 315-322.
  7. ↑ H. Isayama, Y. Komatsu, T. Tsujino: A prospective randomized study of "covered" versus "uncovered" diamond stents for the management of distal malignant biliary obstruction. In: Good. 53, 2004, pp. 729-734.
  8. ^ DL Carr-Locke: Metal stents for distal biliary malignancy: have we got you covered? In: Gastrointest Endosc . 61, 2005, pp. 534-536.
  9. ^ WH Chang, P. Kortan, GB Haber: Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage. In: Gastrointest Endosc. 47, 1998, pp. 354-362.
  10. ↑ BA Radeleff, R. López-Benítez, P. Hallscheidt, L. Grenacher, M. Libicher, GM Richter, GW Kauffmann: Treatment of malignant biliary obstructions via the percutaneous approach. In: Radiologist. 45 (11), Nov 2005, pp. 1020-1030.
  11. ↑ I. Oi, S. Kobayashi, T. Kondo: Endoscopic pancreatocholangiography. In: Endoscopy . 2, 1970, p. 103.
  12. ↑ IS Papanikolaou et al .: Establishment of a training model for percutaneous transhepatic cholangio drainage under MRI guidance. In: Digestive and Liver Disease. 43, 8, August 2011, pp. 642-646. Charité, Berlin (D). CARS 2008 poster presentation

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