Complications of Percutaneous Biliary Procedures

Adverse Events After Percutaneous Transhepatic Biliary Drainage: A 10-Year Retrospective Analysis

PURPOSE

To determine the adverse event (AE) rates and profiles associated with percutaneous transhepatic biliary drainage (PTBD) and to identify risk factors for their occurrence.

MATERIALS AND METHODS

This single-center retrospective study included 2,310 PTBD (right-sided, 1,164; left-sided, 966; bilateral, 180) interventions for biliary obstruction (benign/malignant) in 449 patients between 2010 and 2020. Patients with percutaneous cholecystostomy alone were excluded. There were 455 initial drain placements (66 with cholangioplasty) and 1,855 exchanges (202 with cholangioplasty). Stents were placed in 163 procedures (metal, 156; plastic, 86). Demographic and procedural variables were assessed using multivariate logistic regression.

RESULTS

A total of 745 AEs were recorded. The 3 most common AEs were pericatheter bile leak (331/745, 44.4%), catheter occlusion (110/745, 14.7%), and drain dislodgement (103/745, 13.8%). There was a significantly higher overall AE rate among patients with malignant biliary obstruction than among those with benign biliary obstruction (29.8% vs. 17.6%; odds ratio [OR], 1.57 [1.13-2.18]; P = .006). Intraprocedural cholangioplasty was associated with a decreased AE rate for initial drains and overall procedures (OR, 0.48 [0.25-0.90]; P = .022, and OR, 0.63 [0.45-0.89]; P = .009). Finally, a right-sided drain was associated with an increased overall AE rate for initial drains and overall procedures (OR, 1.62 [1.02-2.55]; P = .039, and OR, 1.43 [1.05-1.91]; P = .017).

CONCLUSIONS

Malignant obstruction and right-sided drains are associated with a higher risk of PTBD-related AEs, whereas intraprocedural cholangioplasty reduces risk. These findings offer insights into how this high-impact procedure can be performed more safely and effectively.

Risk Factors for Premature Exchange of Percutaneous Biliary Drainage in Benign and Malignant Biliary Strictures: A Retrospective Single-Center Study

Introduction

Treating biliary obstruction remains a common clinical problem. Endoscopic retrograde cholangiopancreatography (ERCP) with stent insertion remains the gold standard. If ERCP fails, percutaneous transhepatic biliary drainage (PTBD) is one treatment option. Despite a high success rate, early- and late-onset complications occur frequently, ranging from 20 to 70%. With this study, we aimed to provide further insights on possible risk factors for PTBD-related complications.

Methods

All cases with PTBD placement at our institution over the past 13 years were retrospectively analyzed and median premature exchange rate as well as procedural-associated complications were determined.

Results

A total of 976 PTBDs were inserted in 194 patients. In 853 cases (87%), only one PTBD was inserted. Most patients had a benign disease as an indication for the PTBD insertion (n = 558 cases, 56.9%). A premature PTBD exchange occurred in 246 cases (26%). The most common reason for a premature PTBD exchange or extraction was dislocation (n = 98/39.5%), followed by cholangitis in 70 cases (28.6%). A malignant indication (multivariate p = 0.001 OR = 1.69 95% CI = 1.23-2.30), female sex (multivariate p < 0.001 OR = 2.21 95% CI = 1.56-3.12), and a PTBD ≥14Fr (multivariate p < 0.03 1.50 (1.04-2.11) were associated with a premature stent exchange in the mixed multivariate regression analysis.

Conclusion

Premature exchanges occur frequently in patients treated with PTBD. Especially in patients with malignancy, other interventional bile drainage interventions should be discussed. In case PTBD is chosen, earlier exchange rates than 12 weeks should be considered.

A case of an intraabdominal, but extrahepatic ruptured percutaneous transhepatic biliary drainage and its following rescue. A case report and literature review

Percutaneous transhepatic biliary drainage is a well-established technique for the treatment of biliary obstruction in patients with failed endoscopic approaches. We report on an 82-year-old man with a history of cholangiocarcinoma treated with pancreaticoduodenectomy who presented with recurrent cholangitis and sepsis. Percutaneous transhepatic biliary drainage was performed after unsuccessful endoscopic retrograde cholangiography, which initially improved his condition. However, due to an accidental dislodgement, there was an intra-abdominal fracture of the drain which led to biliary peritonitis and clinical deterioration. The fractured intrahepatic drain was successfully extracted in our angio suite, and a novel subcutaneous fixation technique was introduced to prevent similar occurrences in the future. This case study signifies the role of interventional radiology in the management of percutaneous transhepatic biliary drainage complications and the importance of preventative measures to avoid dislodgement.

Cell-Free Tumor DNA Detection-Based Liquid Biopsy of Plasma and Bile in Patients with Various Pancreatic Neoplasms

The key challenge of cell-free tumor DNA (cftDNA) analysis in pancreatic ductal adenocarcinoma (PDAC) is overcoming its low detection rate, which is mainly explained by the overall scarcity of this biomarker in plasma. Obstructive jaundice is a frequent event in PDAC, which enables bile collection as a part of routine treatment. The aim of this study was to evaluate the performance of KRAS-mutated cftDNA detection-based liquid biopsy of plasma and bile in patients with pancreatic neoplasms using digital droplet PCR. The study included healthy volunteers (n = 38), patients with PDAC (n = 95, of which 20 had obstructive jaundice) and other pancreatic neoplasms (OPN) (n = 18). The sensitivity and specificity compared to the control group were 61% and 100% (AUC-ROC-0.805), and compared to the OPN group, they were 61% and 94% (AUC-ROC-0.794), respectively. Bile exhibited higher cftDNA levels than plasma (248.6 [6.743; 1068] vs. 3.26 [0; 19.225] copies/mL) and a two-fold higher detection rate (p < 0.01). Plasma cftDNA levels were associated with distant metastases, tumor size, and CA 19-9 (p < 0.05). The probability of survival was worse in patients with higher levels of cftDNA in plasma (hazard ratio-2.4; 95% CI: 1.3-4.6; p = 0.005) but not in bile (p > 0.05). Bile is a promising alternative to plasma in patients with obstructive jaundice, at least for the diagnostic purposes of liquid biopsy.

Comparison of trans-gastric vs trans-enteric (trans-duodenal or trans-jejunal) endoscopic ultrasound guided gallbladder drainage using lumen apposing metal stents

BACKGROUND

Endoscopic ultrasound guided gallbladder drainage (EUS-GBD) is being increasingly used in practice (either as a bridge to cholecystectomy in high-risk patients or as destination therapy in non-surgical patients). Stents are used to create a conduit between the lumen of the gallbladder (GB) and the intestinal lumen through the gastric or enteric routes. Among the various types of stents used, cautery-enhanced lumen apposing metallic stents (LAMS) may be associated with fewer adverse events (AEs).

AIM

To compare the clinical success, technical success, and rate of AEs between transgastric (TG) and trans-enteric [transduodenal (TD)/transjejunal (TJ)] approach to GB drainage. Further, we analyzed whether using cautery enhanced stents during EUS-GBD impacts the above parameters.

METHODS

Study was registered in PROSPERO (CRD42022319019) and comprehensive literature review was conducted. Manuscripts were reviewed for the data collection: Rate of AEs, clinical success, and technical success. Random effects model was utilized for the analysis.

RESULTS

No statistically significant difference in clinical and technical success between the TD/TJ and TG approaches (P > 0.05) were noted. There was no statistically significant difference in the rate of AEs when comparing two-arm studies only. However, when all studies were included in the analysis difference was almost significant favoring the TD/TJ approach. When comparing cautery-enhanced LAMS with non-cautery enhanced LAMS, a statistically significant difference in the rate of AEs was observed when all the studies were included, with the rate being higher in non-cautery enhanced stents (14.0% vs 37.8%; P < 0.01).

CONCLUSION

As per our study results, TD/TJ approach appears to be associated with lower rate of adverse events and comparable efficacy when compared to the TG approach for the EUS-GBD. Additionally, use of cautery-enhanced LAMS for EUS-GBD is associated with a more favorable adverse event profile compared to cold LAMS. Though the approach chosen depends on several patient and physician factors, the above findings could help in deciding the ideal drainage route when both TG and TD/TJ approaches are feasible.

Readiness for hospital discharge post-initial invasive percutaneous transhepatic biliary drainage: A mixed-methods study

This study explores perceptions regarding hospital discharge readiness among patients with post-first invasive percutaneous transhepatic biliary drainage (PTBD), family caregivers, and healthcare providers who are involved during the discharge period. A convergent mixed-method design was applied. A purposive sample of 30 patients completed a scale measuring readiness for hospital discharge, and 30 participants, including patients, family caregivers, and healthcare providers, participated in in-depth interviews. Descriptive analyses were combined with quantitative data, thematic analyses with qualitative data, and joint displays with mixed analyses. Findings indicate that readiness for hospital discharge was high, the expected support subscale was at the highest possible level, and the personal status subscale was at the lowest level. Three main themes emerged from an analysis of the interview transcripts: improved health conditions, self-care knowledge, and homecare preparedness. Self care knowledge had three sub-themes: taking care of biliary drainage, consuming a suitable diet, and observation of abnormal symptoms. Being ready for hospital discharge contributes to a safer transition from hospital to home. Healthcare providers need to reconsider the criteria for discharge and clarify patients' individual needs. Patients, family caregivers, and healthcare providers need to be prepared for hospital discharge.

Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are currently first- and second-line therapeutic options, respectively, for the relief of biliary obstruction. In recent years, however, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an established alternative therapy for biliary obstruction. There are multiple different techniques for EUS-BD, which can be distinguished based on the access point within the biliary tree (intrahepatic versus extrahepatic) and the location of stent placement (transenteric versus transpapillary). The clinical and technical success rates of biliary drainage for EUS-BD are similar to both ERCP and PTBD, and complication rates are favorable for EUS-BD relative to PTBD. As EUS-BD becomes more widely practiced and endoscopic tools continue to advance, the outcomes will likely improve, and the breadth of indications for EUS-BD will continue to expand.

Does percutaneous cholecystostomy timing in high anaesthetic-risk patients impact on outcome?

The optimal timing for percutaneous cholecystostomy (PCT) in patients with acute biliary sepsis, who are high-risk for cholecystectomy, requires further investigation. We aimed to study local factors influencing the timing to PCT placement, and investigate patient outcomes in early (≤ 48 h) vs. delayed PCT over a six-year period. A retrospective observational study investigating patients who required a PCT at a single hospital in the UK between January 2014 and December 2019. Placement of a PCT was at the discretion of the on-call surgical consultant according to their own personal experience and not based on a standard local protocol. Clinical outcomes, hospital statistics and details of any subsequent bridging surgery were analysed using multivariate logistic regression models adjusting for age, sex, Charlson Comorbidity Index (CCI) and American Society of Anaesthesiologists (ASA) grade. There were 72 patients with 35/72 (48.6%) classed as TG18 AC grade 3; 26/72 (36.1%) had an early PCT placed and 46/72 (63.9%) delayed. Median age was 76 (65-83) years, 52.8% were female, and 51.4% were classed ASA ≥ 3 with 94.0% scoring CCI > 2. Trial on antibiotic therapy was the primary reason for delayed PCT. In adjusted models, early PCT was associated with a shorter length in hospital stay (OR 3.02, p = 0.044), successful definitive treatment (OR 6.26, p = 0.009); and reduced likelihood for catheter dislodgment (OR 0.12, p = 0.004) with fewer patients bridging to later emergency open surgery (OR 0.19, p = 0.024). Clinical outcomes may be superior in urgent or early PCT for high anaesthetic-risk patients following acute biliary sepsis.

Research Priorities in Percutaneous Image and Endoscopy Guided Interventions for Biliary and Gallbladder Diseases: Proceedings from the Society of Interventional Radiology Foundation Multidisciplinary Research Consensus Panel

Recent technological advancements including the introduction of disposable endoscopes have enhanced the role of interventional radiology (IR) in the management of biliary/gallbladder diseases. There are unanswered questions in this growing field. The Society of Interventional Radiology Foundation convened a virtual Research Consensus Panel consisting of a multidisciplinary group of experts, to develop a prioritized research agenda regarding percutaneous image and endoscopy guided procedures for biliary and gallbladder diseases. The panelists discussed current data, opportunities for IR and future efforts to maximize IR's ability and scope. A recurring theme throughout the discussions was to find ways to reduce the total duration of percutaneous drains and to improve the patients' quality of life. Following the presentations and discussions, research priorities were ranked based on their clinical relevance and impact. The research ideas ranked top three were as follows: 1- Percutaneous multimodality management of benign anastomotic biliary strictures (Laser vs endobiliary ablation vs cholangioplasty vs drain upsize protocol alone); 2- Ablation of intraductal cholangiocarcinoma with and without stenting; and 3- Cholecystoscopy/choledochoscopy and lithotripsy in non-surgical patients with calculous cholecystitis. Collaborative retrospective and prospective research studies are essential to answer these questions and to improve the management protocols for patients with biliary/gallbladder diseases.