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Khayat A, Khayat M, Cline M, Riaz A. Percutaneous Biliary Endoscopy. Semin Intervent Radiol 2021; 38:340-347. [PMID: 34393344 DOI: 10.1055/s-0041-1731372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Biliary endoscopy is underutilized by interventional radiologists and has the potential to become an effective adjunctive tool to help both diagnose and treat a variety of biliary pathology. This is particularly true in cases where endoscopic retrograde cholangiopancreatography fails or is not feasible due to surgically altered anatomy. Both preoperative clinical and technical procedural factors must be taken into consideration prior to intervention. In this article, clinical evaluation, perioperative management, and procedural techniques for percutaneous biliary endoscopy are reviewed.
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Affiliation(s)
- Adam Khayat
- NYU Long Island School of Medicine, Mineola, New York
| | - Mamdouh Khayat
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael Cline
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ahsun Riaz
- Division of Vascular and Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
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Riaz A, Entezari P, Ganger D, Gabr A, Thornburg B, Russell E, Ladner D, Katariya N, Caicedo JC, Boike J, Lewandowski RJ, Keswani R, Aadam AA, Abecassis M, Salem R. Percutaneous Access of the Modified Hutson Loop for Retrograde Cholangiography, Endoscopy, and Biliary Interventions. J Vasc Interv Radiol 2020; 31:2113-2120.e1. [PMID: 32948389 DOI: 10.1016/j.jvir.2020.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The purpose of this study was to present the institutional experience of performing endoscopy, cholangiography, and biliary interventions through the modified Hutson loop by interventional radiology. MATERIALS AND METHODS A total of 61 of 64 modified Hutson loop access procedures were successful. This single-center retrospective study included 61 successful procedures of biliary interventions using existing modified Hutson loops (surgically affixed subcutaneous jejunal limb adjacent to biliary anastomosis or anastomoses) for diagnostic or therapeutic purposes in 21 patients. Seventeen of 21 patients (81%) had undergone liver transplantation. Indications included biliary strictures (n = 18) and biliary leaks (n = 3). The clinical success and complications were evaluated. RESULTS There were 3 of 26 modified Hutson loop retrograde biliary intervention failures (12%) before introduction of endoscopy and no failures (0 of 38 [0%]) subsequently (P = .06). Endoscopy or cholangioscopy was performed in 19 procedures by interventional radiologists. Retrograde biliary interventions included diagnostic cholangiography (n = 26), cholangioplasty (n = 25), stent placement (n = 29), stent retrieval (n = 25), and biliary drainage catheter placement (n = 5). No procedure-related mortality occurred. There was 1 major complication (duodenal perforation) (1.6%) and 12 minor complications (19%). In the 9 patients undergoing therapeutic interventions for biliary strictures, there was a significant decrease in median alkaline phosphatase (288.5 to 174.5 U/L; P = .03). There was a trend toward decrease in median bilirubin levels (1.7 to 1 mg/dL; P = .06) at 1 month post-intervention. CONCLUSIONS The modified Hutson loop provided interventional radiologists a safe and effective alternative access to manage biliary complications in patients with biliary-enteric anastomoses. Introduction of the endoscope in interventional radiology has improved the success rate of these procedures.
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Affiliation(s)
- Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois.
| | - Pouya Entezari
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Elliott Russell
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Daniela Ladner
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, Illinois
| | - Nitin Katariya
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, Illinois
| | - Juan Carlos Caicedo
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, Illinois
| | - Justin Boike
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Rajesh Keswani
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Abdul Aziz Aadam
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
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Houghton E. Complex percutaneous biliary procedures: Review and contributions of a high volume team. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii180036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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4
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Wnuk N, Pabon-Martinez AM, Mahvash A, Chintalapani G, Aloia TA, Odisio BC. Percutaneous-transhepatic creation of a bilioenteric neoanastomosis in a patient with bile duct injury using cone-beam computed tomography. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii180037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - Armeen Mahvash
- Department of Vascular and Interventional Radiology, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Thomas A. Aloia
- Department of Surgical Oncology, Division of Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Bruno C. Odisio
- Department of Vascular and Interventional Radiology, MD Anderson Cancer Center, Houston, TX, USA
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Kim D, Bolus C, Iqbal SI, Davison BD, Ahari HK, Flacke S, Molgaard CP. Percutaneous Transjejunal Biliary Access in 60 Patients with Bilioenteric Anastomoses. J Vasc Interv Radiol 2018; 30:76-81.e1. [PMID: 30316675 DOI: 10.1016/j.jvir.2018.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To determine success and complication rates of percutaneous transjejunal biliary access (PTJBA) in patients with bilioenteric anastomoses. MATERIALS AND METHODS In a single-center, retrospective study, 169 PTJBA procedures were performed over a 13.8-y period in 60 subjects (47 male; mean age, 54.5 y). Indications for biliary interventions were cholangitis (137 cases, 45 subjects) or hyperbilirubinemia (32 cases, 18 subjects). All patients had antecolic bilioenteric anastomoses without surgical fixation to the peritoneum (liver transplantation with hepaticojejunostomy, n = 37; hepatectomy with hepaticojejunostomy, n = 8; hepaticojejunostomy only, n = 12; pancreaticoduodenectomy, n = 3). RESULTS Initial PTJBA was successful in 140 cases (82.8%) in 35 subjects (58.3%). Twenty-one additional PTJBAs (12.4%) in 18 subjects (30.0%) were performed secondarily following a conventional transhepatic approach. Radiographic markers on the Roux-en-Y limb (P = .14, odds ratio [OR] = 2.98) or preprocedural imaging (P = .13, OR = 10.00) did not increase the odds of successful PTJBA. There were 7 major complications (4.3%) in 6 patients (10.0%) requiring hospitalization longer than 5 d, and 37 minor complications (23.0%) in 19 patients (31.7%). No procedure-related mortality was observed. Minor and major complication rates were not affected by time between bilioenteric anastomosis creation and PTJBA (P = .70, OR = 1.00; P = .62, OR = 1.00), longer dwell time of a transjejunal drain (P = .68, OR = 1.02; P = .49, OR = 0.71), or access size (P = .40, OR = 0.85; P = .23, OR = 0.59). CONCLUSIONS PTJBA is a relatively safe technique with a high success rate in patients with bilioenteric loops that are not surgically fixed to the peritoneum.
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Affiliation(s)
- DaeHee Kim
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805.
| | - Christopher Bolus
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Shams I Iqbal
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Brian D Davison
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Heideh K Ahari
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Sebastian Flacke
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
| | - Christopher P Molgaard
- Department of Radiology, Lahey Hospital and Medical Center, 41 Mall Rd., Burlington, MA 01805
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Severini A, Cozzi G, Salvetti M, Mazzaferro V, Doci R. Management of Complications from Hepatobiliary Surgery Using the Percutaneous Trans Jejunal Approach. TUMORI JOURNAL 2018; 83:912-7. [PMID: 9526583 DOI: 10.1177/030089169708300608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The work was aimed at presenting the indications, techniques and results of the percutaneous transjejunal approach to the biliary tree in patients with hepatobiliary complications due to surgery. Patients and methods Ten patients, 7 males and 3 females, mean age 50 years (range, 10–62) with hepatico-jejunostomy, who developed cholangitis together with jaundice or bile leakage, underwent this procedure, performed through the anastomotic loop that was not surgically anchored to the abdominal wall in all cases but one. The transjejunal approach was chosen because of non-dilated bile ducts in 3 patients, complex pathologic situations in 5 patients and to avoid complications to a transplanted liver in 2 patients. The jejunal loop was identified using CT, US and fluoroscopy in 4 patients and after its opacification in the remaining 6 (by percutaneous transhepatic or intravenous cholangiography or fistulography). Results The procedure was technically and diagnostically successful in all cases. Therapeutic procedures (stenting, dilation, litholysis) were also performed using the transjejunal approach in 7 patients and in 6 of them complete pathological resolution was achieved. There were no complications. Conclusions Different pathologies of the biliary tree, in patients with bilio-enteric anastomoses, have been identified and treated by this technique; they were fistulas, anastomotic and/or multiple segmental benign or malignant stenoses of the bile duct, and diffuse intrahepatic lithiasis. The procedure was safe and reliable.
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Affiliation(s)
- A Severini
- Department of Radiology, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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Lopera JE, Hegg R, Bready E, Kroma G, Garza-Berlanga A, Suri R. Complex biliary intervention: Percutaneous small bowel access confirmation with cone-beam computed tomography and retrograde biliary obstruction recanalization. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jorge E Lopera
- Department of Radiology, University of Texas Health Science Center at San Antonio, University of Texas School of Medicine at San Antonio, San Antonio, TX, USA
| | - Ryan Hegg
- Department of Radiology, University of Texas Health Science Center at San Antonio, University of Texas School of Medicine at San Antonio, San Antonio, TX, USA
| | - Eric Bready
- Department of Radiology, University of Texas Health Science Center at San Antonio, University of Texas School of Medicine at San Antonio, San Antonio, TX, USA
| | - Ghazwan Kroma
- Department of Radiology, University of Texas Health Science Center at San Antonio, University of Texas School of Medicine at San Antonio, San Antonio, TX, USA
| | - Andres Garza-Berlanga
- Department of Radiology, University of Texas Health Science Center at San Antonio, University of Texas School of Medicine at San Antonio, San Antonio, TX, USA
| | - Rajeev Suri
- Department of Radiology, University of Texas Health Science Center at San Antonio, University of Texas School of Medicine at San Antonio, San Antonio, TX, USA
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8
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Combined Surgical and Transhepatic Rendezvous Procedure for Relieving Anastomotic Biliary Obstruction in Children with Liver Transplants. J Vasc Interv Radiol 2017; 28:1189-1193. [PMID: 28735936 DOI: 10.1016/j.jvir.2016.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/16/2016] [Accepted: 06/16/2016] [Indexed: 01/02/2023] Open
Abstract
Four children (3 boys and 1 girl, age 1.4-9.4 y) presented 2-70 months after liver transplantation (mean 26 months) with high-grade narrowing at the surgical anastomosis that could not be crossed at percutaneous transhepatic cholangiography. Each patient was treated with a combined surgical and interventional radiology "rendezvous" procedure. Biliary drainage catheters were left in place for an average of 6 months after the procedure. At a mean 7.5 months after biliary drainage catheter removal, all children were catheter-free without clinical or biochemical evidence of biliary stricture recurrence.
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Retrograde Percutaneous Transjejunal Creation of Biliary Neoanastomoses in Patients with Complete Hepaticojejunostomy Dehiscence. J Vasc Interv Radiol 2016; 26:1544-9. [PMID: 26408218 DOI: 10.1016/j.jvir.2015.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 04/27/2015] [Accepted: 06/02/2015] [Indexed: 12/26/2022] Open
Abstract
A technique of percutaneous hepaticojejunostomy (PHJ) was developed to allow creation of a neoanastomosis in cases of hepaticojejunostomy (HJ) dehiscence when endoscopic intervention is unfeasible as a result of postsurgical anatomy. PHJ involves transhepatic biliary catheterization and transjejunal retrograde enterotomy. A rendezvous establishes the communication between the bile ducts and the jejunum. PHJ was performed in five patients, and neoanastomosis creation without residual biliary leak was achieved in all cases, with no procedure-related complications. Bilirubin levels and white blood cell counts quickly decreased after PHJ (median, 1 d; range, 1-4 d). Median survival after PHJ was 210 days (range, 45-540 d).
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10
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Lopera JE, Ramsey GR. Transjejunal biliary interventions: going back to a road less traveled. Acta Radiol 2014; 55:1210-8. [PMID: 24316661 DOI: 10.1177/0284185113515476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Percutaneous transhepatic biliary interventions are not without risk and potential complications. In patients with bilioenteric anastomosis in whom repeat biliary interventions are expected, percutaneous transjejunal access is a very useful approach that is not frequently used nowadays. We provide a brief review of the history, indications, and current status of transjejunal biliary interventions. Transjejunal biliary access provides a relatively atraumatic pathway to the biliary system in patients that need repeat interventions. Multiple studies have provided convincing data that in appropriately chosen patients receiving a bilioenteric anastomosis, an antecolic limb of jejunum should be placed for subsequent access in biliary intervention.
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Affiliation(s)
- Jorge E Lopera
- Department of Radiology, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Gregory R Ramsey
- Department of Radiology, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
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Liu GP, Zhu WX, Cheng GM, Ma SR. Therapeutic transjejunal endoscopy for the treatment of biliary complications after choledochojejunostomy. Exp Ther Med 2013; 5:499-502. [PMID: 23403492 PMCID: PMC3570081 DOI: 10.3892/etm.2012.815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 11/02/2012] [Indexed: 02/06/2023] Open
Abstract
The present study aimed to assess the value of endoscopic jejunostomy for post-biliary intestinal anastomosis biliary complications. The clinical data of the endoscopic therapies by jejunal approach for post-biliary intestinal anastomosis biliary complications in 13 patients (16 surgeries in total) were retrospectively analyzed. The surgical success rate was 100% (16/16). Nasobiliary tube detention was performed for 2 patients, plastic stent placement for 5 and biliary metal stent placement for 4. The remaining two patients did not retain any drainage tube or bracket after surgery. The incidence rate of intraoperative anastomotic stenostomia was 76.9% (10/13). A noticeable postoperative decrease in bilirubin levels was observed in 10 patients. The level of gallstone-free patients was 75% (3/4). There were 10 cases in which cholangitis remission or no attack was identified. Post-operative incisional infection occurred in 3 patients, hepatophyma in 1 and an intestinal fistula in 1. Endoscopic therapy by jejunal approach for post-biliary intestinal anastomosis biliary complications has the virtue of being safe, effective and minimally invasive. It has extensive potential applications in clinical practice.
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Affiliation(s)
- Guo-Ping Liu
- Department of General Surgery, Changhai Hospital, The Second Military Medical University, Shanghai 200433
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12
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Multidisciplinary Practical Guidelines for Gastrointestinal Access for Enteral Nutrition and Decompression From the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, With Endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). J Vasc Interv Radiol 2011; 22:1089-106. [DOI: 10.1016/j.jvir.2011.04.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 04/08/2011] [Accepted: 04/08/2011] [Indexed: 12/16/2022] Open
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Itkin M, DeLegge MH, Fang JC, McClave SA, Kundu S, d'Othee BJ, Martinez-Salazar GM, Sacks D, Swan TL, Towbin RB, Walker TG, Wojak JC, Zuckerman DA, Cardella JF. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). Gastroenterology 2011; 141:742-65. [PMID: 21820533 DOI: 10.1053/j.gastro.2011.06.001] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 04/08/2011] [Indexed: 02/06/2023]
Affiliation(s)
- Maxim Itkin
- Department of Radiology, Division of Interventional Radiology, University of Pennsylvania Medical Center, Pennsylvania Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.
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Two decades of percutaneous transjejunal biliary intervention for benign biliary disease: a review of the intervention nature and complications. Insights Imaging 2011; 2:557-65. [PMID: 23100019 PMCID: PMC3289021 DOI: 10.1007/s13244-011-0119-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 06/29/2011] [Accepted: 07/11/2011] [Indexed: 12/29/2022] Open
Abstract
Objective To assess outcomes of percutaneous transjejunal biliary intervention (PTJBI) in terms of success and effectiveness in patients with a Roux-en-Y hepaticojejunostomy for benign biliary strictures and stones. Methods Clinical and radiographic records of 63 patients with a Roux-en-Y choledochojejunostomy or hepaticojejunostomy for benign disease who underwent at least one PTJBI between 1986 and 2007 were reviewed. Effectiveness was determined by successful access rate, rates of stricture dilatation and/or stone extraction, morbidity, complications and hospitalisation. Results PTJBI was attempted 494 times. Successful access to the Roux-en-Y was accomplished in 93% of interventions. After access to the Roux-en-Y was granted, all strictures were effectively dilated. Ninety-seven percent of extraction attempts of intrahepatic calculi were successful. The median number of interventions per patient was five. The median interval between interventions was 51.5 weeks (range 2.7–1,279.6 weeks). The early complication rate was 3%. Morbidity, measured in terms of cholangitis episodes was 14%, in 25 out of 63 patients. Mean hospitalisation was 4.1 nights per year. Conclusion PTJBI is safe and effective in treating benign biliary strictures and/or calculi. High success rates and short hospitalisation periods, together with few complications make it a well-accepted and integral part of managing complex biliary problems.
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Laasch HU. Obstructive jaundice after bilioenteric anastomosis: transhepatic and direct percutaneous enteral stent insertion for afferent loop occlusion. Gut Liver 2010; 4 Suppl 1:S89-95. [PMID: 21103301 DOI: 10.5009/gnl.2010.4.s1.s89] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Recurrent tumour after radical pancreaticoduodenectomy may cause obstruction of the small bowel loop draining the liver. Roux-loop obstruction presents a particular therapeutic challenge, since the postsurgical anatomy usually prevents endoscopic access. Careful multidisciplinary discussion and multimodality preprocedure imaging are essential to accurately demonstrate the cause and anatomical location of the obstruction. Transhepatic or direct percutaneous stent placement should be possible in most cases, thereby avoiding long-term external biliary drainage. Gastropexy T-fasteners will secure the percutaneous access and reduce the risk of bile leakage. The static bile is invariably contaminated by gut bacteria, and systemic sepsis is to be expected. Enteral stents are preferable to biliary stents, and compound covered stents in a sandwich construction are likely to give the best long-term results. Transhepatic and direct percutaneous enteral stent insertion after jejunopexy is illustrated and the literature reviewed.
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Affiliation(s)
- Hans-Ulrich Laasch
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
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16
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Amitha Vikrama KS, Keshava SN, Surendrababu NRS, Moses V, Joseph P, Vyas F, Sitaram V. Jejunal access loop cholangiogram and intervention using image guided access. J Med Imaging Radiat Oncol 2010; 54:5-8. [PMID: 20377708 DOI: 10.1111/j.1754-9485.2010.02130.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Jejunal access loop is fashioned in patients who undergo Roux en Y hepaticojejunostomy and biliary intervention is anticipated on follow up. Post-operative study of the biliary tree through the access loop is usually done under fluoroscopic guidance. We present a series of 20 access loop cholangiograms performed in our institution between August 2004 and November 2008. We aimed to evaluate the safety and efficacy of the procedure and to highlight the role of CT guidance in procuring access. Access loop was accessed using CT (n = 13), ultrasound (n = 3) or fluoroscopic guidance (n = 4). Fluoroscopy was used for performing cholangiograms and interventions. Twelve studies had balloon plasty of the stricture at anastomotic site or high up in the hepatic ducts. Seven studies showed normal cholangiogram. Plasty was unsuccessful in one study. Technical success in accessing the jejunal access loop was 100%; in cannulation of anastomotic site and balloon plasty it was 95%. One case required two attempts. Procedure-related complications were not seen. All patients who underwent balloon plasty of the stricture were doing well for variable lengths of time. Access loop cholangiogram and interventions are safe and effective. CT guidance in locating/procuring the access loop is a good technique.
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Iwamuro M, Kawamoto H, Harada R, Kato H, Hirao K, Mizuno O, Ishida E, Ogawa T, Okada H, Yamamoto K. Combined duodenal stent placement and endoscopic ultrasonography-guided biliary drainage for malignant duodenal obstruction with biliary stricture. Dig Endosc 2010; 22:236-40. [PMID: 20642617 DOI: 10.1111/j.1443-1661.2010.00997.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Patients with malignant pancreatobiliary neoplasm sometimes manifest duodenal obstruction and biliary stricture synchronously or metachronously. In this paper, we reviewed our experience with and technique for combined endoscopic duodenal stent placement and endoscopic ultrasonography (EUS)-guided biliary drainage. Between May 2007 and September 2009, this combined technique was performed on seven patients with distal biliary strictures and duodenal obstructions. The clinical success rate of the procedure, complications, patency periods of duodenal stents and patency periods of biliary stents were retrospectively evaluated. Clinical success was achieved in all seven cases for both procedures. Complications related to EUS-biliary drainage, namely localized peritonitis due to bile leakage, occurred in two cases. Both patients recovered without additional interventions. Occlusion of a duodenal stent was observed in one patient, but additional intervention could not be performed due to sepsis. Occlusion of both a duodenal stent and a biliary stent was also observed in one patient, and this was resolved with the insertion of an additional duodenal stent and a biliary stent exchange. In conclusion, combined duodenal stent placement and EUS-guided biliary drainage is a therapeutic option in case of failed endoscopic retrograde cannulation of malignant strictures with a malignant duodenal obstruction.
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Affiliation(s)
- Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Sparrow P, David E, Pugash R. Direct percutaneous jejunostomy--an underutilized interventional technique? Cardiovasc Intervent Radiol 2007; 31:336-41. [PMID: 17943346 DOI: 10.1007/s00270-007-9199-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2007] [Revised: 09/05/2007] [Accepted: 09/25/2007] [Indexed: 01/19/2023]
Abstract
Our aim in this study was to report our single-center experience with direct percutaneous jejunostomy over a 4-year period with regard to technical success rate, immediate and late complications, and patient tolerance of the procedure. Institutional records of 22 consecutive patients who underwent radiological insertion of a percutaneous jejunostomy for a variety of indications were reviewed. The proximal jejunum was punctured under either fluoroscopic or ultrasonic guidance, and following placement of retention sutures, a 10- to 12-Fr catheter inserted. There was a 100% technical success rate in placement involving a total of seven operators. The indications for placement were prior gastric resection, newly diagnosed resectable esophageal or gastric carcinoma, unresectable gastric carcinoma with outlet obstruction, and palliative drainage of bowel obstruction. Mean duration of follow-up was 100 days, and catheter placement 57.7 days. There were six minor early complications, consisting of loss of two retention anchors requiring repuncture, three cases of localized excessive postprocedural pain, and one failed relief of symptoms of small bowel obstruction. Four tubes developed late complications (two blocked, one catheter cracked, and one inadvertently pulled out). Three of the four were successfully replaced through the existing tracts. One patient subsequently developed a minor skin infection, while another developed late pericatheter leakage from ascites. We conclude that direct percutaneous jejunostomy is a valuable treatment modality applicable to a number of clinical scenarios, with a high technical success rate and low serious complication rate.
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Affiliation(s)
- Patrick Sparrow
- Department of Vascular and Interventional Radiology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
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Abbas HMH, Yassin NA, Ammori BJ. Laparoscopic Resection of Type I Choledochal Cyst in an Adult and Roux-en-Y Hepaticojejunostomy: A Case Report and Literature Review. Surg Laparosc Endosc Percutan Tech 2006; 16:439-44. [PMID: 17277665 DOI: 10.1097/01.sle.0000213768.70923.99] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Choledochal cysts are rare cystic dilatations of the extrahepatic biliary tree, the intrahepatic bile ducts, or both and carry a substantial risk of malignant transformation. Type I choledochal cysts, which involve the entire common hepatic and common bile ducts, represent 80% to 90% of these lesions. We report laparoscopic excision of symptomatic type I choledochal cyst in a 37-year-old woman, and review the literature. Laparoscopic excision of the extrahepatic biliary tree from the hepatic confluence to the anomalous pancreatobiliary junction with en bloc cholecystectomy and reconstruction with a Roux-en-Y hepaticojejunostomy was accomplished. Postoperative recovery was uneventful with a hospital stay of 3 days. She remains well and asymptomatic at 6 months of follow-up. Laparoscopic excision of choledochal cysts may be safely accomplished with a prompt recovery. Further experience with this approach in larger number of patients is justified and long-term follow-up data are needed.
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Affiliation(s)
- Hasan M H Abbas
- Department of Surgery, Manchester Royal Infirmary, Manchester, UK
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Ramesh H, Prakash K, Kuruvilla K, Philip M, Jacob G, Venugopal B, Lekha V, Varma D. Biliary access loops for intrahepatic stones: results of jejunoduodenal anastomosis. ANZ J Surg 2003; 73:306-12. [PMID: 12752287 DOI: 10.1046/j.1445-2197.2003.t01-1-02623.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with intrahepatic calculi require multiple interventions following successful surgical stone clearance for recurrent stones and cholangitis. The present paper describes the results of a technique of in-continuity side-to-side jejunoduodenal anastomosis (JDA) that provides endoscopic access to the hepaticojejunostomy and intrahepatic ducts. This operation is compared to other techniques in a critical appraisal of various biliary access procedures described for long-term management of intrahepatic -calculi. METHODS A retrospective analysis of clinical data of 13 patients who underwent biliary drainage procedures with access loops for intrahepatic calculi during the period March 1990 to December 2000 was performed. The postoperative course of patients and the feasibility of postoperative endoscopic access to the hepaticojejunostomy and intrahepatic ductal system in treatment of recurrent cholangitis were assessed. Nine patients underwent JDA, two underwent permanent-access hepaticojejunostomy (PAH) and two others underwent an interposition hepaticojejunoduodenostomy (IHJ). RESULTS The analysis revealed no major procedure-related complications or mortality. Endoscopic access (using forward-viewing gastroscope) was possible in 100% of cases following JDA, and with difficulty in both cases after PAH. Endoscopic access in the two patients with IHJ failed because of technical reasons. Recurrent cholangitis was seen in seven patients (54%) - two out of two patients in the PAH group, one out of two in the IHJ group and four out of nine in the JDA group. This required 12 endotherapy sessions (mean: 1.5 procedures per patient). CONCLUSION In-continuity side-to-side JDA allows easy access of conventional gastroduodenoscopes to the biliary tree for removal of recurrent/residual intrahepatic stones. The technique has advantages over other access loop procedures in the long term management of recurrent intrahepatic stones.
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Affiliation(s)
- Hariharan Ramesh
- Department of GI Surgery, Digestive Diseases Center, PVS Memorial Hospital, Cochin, Kerala, India.
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21
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Burmester E, Niehaus J, Leineweber T, Huetteroth T. EUS-cholangio-drainage of the bile duct: report of 4 cases. Gastrointest Endosc 2003; 57:246-51. [PMID: 12556796 DOI: 10.1067/mge.2003.85] [Citation(s) in RCA: 185] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiography with stent insertion is an established procedure for palliation of patients with malignant pancreaticobiliary strictures. In some patients, however, placement of a stent by means of a duodenoscope is not possible. Percutaneous transhepatic biliary drainage is an alternative method that has a complication rate of up to 15%. Four cases of successful EUS-guided-cholangio-drainage are presented in which the major papilla could not be cannulated at endoscopic retrograde cholangiography. METHODS For puncture of the intrahepatic or extrahepatic bile duct, a modification of the one-step technique for the drainage of pancreatic pseudocysts was used. RESULTS Stent insertion was successful in 3 of the 4 patients. In these 3 patients cholestasis resolved promptly. CONCLUSIONS EUS-guided cholangio-drainage is a potential alternative to percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiography in the therapy of malignant pancreaticobiliary strictures, especially in patients who have undergone gastrectomy or partial gastrectomy with Billroth II reconstruction.
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Affiliation(s)
- Eike Burmester
- Krankenhaus Sued, Abteilung für Gastroenterologie, Innere Medizin, Luebeck, Germany
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Perry LJ. Percutaneous biliary drainage in patients with nondilated bile ducts: use of a transjejunal approach. AJR Am J Roentgenol 2000; 175:268. [PMID: 10882287 DOI: 10.2214/ajr.175.1.1750268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Kitamura H, Miwa S, Nakata T, Nomura K, Tanaka T, Ikegami T, Miyagawa S, Kawasaki S. Sonographic detection of visceral adhesion in percutaneous drainage of afferent-loop small-intestine obstruction. JOURNAL OF CLINICAL ULTRASOUND : JCU 2000; 28:133-136. [PMID: 10679700 DOI: 10.1002/(sici)1097-0096(200003/04)28:3<133::aid-jcu5>3.0.co;2-j] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
To facilitate the percutaneous drainage of an afferent-loop small-intestine obstruction, we used sonography to detect visceral adhesions and select a safe puncture route. The portion of the small intestine that was fixed to the anterior abdominal wall was sonographically identified by using a high-frequency transducer to locate the area of restricted visceral sliding. The needle was then inserted into the intestine. In 3 cases, we have found that this technique improves the confidence of the physicians who perform the percutaneous drainage and may help to minimize the risks associated with the percutaneous drainage.
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Affiliation(s)
- H Kitamura
- First Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-0802, Japan
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Röthlin MA, Löpfe M, Schlumpf R, Largiadèr F. Long-term results of hepaticojejunostomy for benign lesions of the bile ducts. Am J Surg 1998; 175:22-6. [PMID: 9445233 DOI: 10.1016/s0002-9610(97)00229-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hepaticojejunostomy has been the method of choice for the treatment of benign lesions of the extrahepatic bile ducts for years. In the era of minimally invasive and interventional techniques, a review of its long-term results is necessary to set the standard with which these new techniques have to be compared. METHODS A retrospective analysis was carried out for 51 patients (16 females, 35 males) aged 24 to 83 years (average 48 +/- 13) who had undergone hepaticojejunostomy for benign lesions at our institution between 1980 and 1989. Twelve patients had had up to 4 prior operations of their bile ducts. The main indications for operation were chronic pancreatitis (n = 33) and iatrogenic bile duct lesions (n = 15). If possible, a low end-to-side hepaticojejunostomy was performed. The Hepp-Couinaud approach was saved for high strictures and recurrences. All patients were reassessed by questionnaire at an average of 7.6 years (range 2 to 13) after the operation. RESULTS Four Hepp-Couinaud and 47 low hepaticojejunostomies were performed. Postoperative complications were seen in 17 patients (33%), 4 of whom had a reoperation. One patient died, for a mortality rate of 2%. The hospital stay averaged 24 +/- 17 days (range 8 to 90). Late complications developed in 13 patients (25%) 2 months to 6 years after the operation. Stenosis and cholangitis necessitated reoperation in 3 cases, cholangitis without stenosis was treated in 4, and other complications were seen in 5 cases. One patient died with a liver abscess, and 12 died of causes unrelated to the operation. When questioned, 31 of 35 patients were in good or very good condition. CONCLUSIONS Hepaticojejunostomy is a safe and reliable method for the treatment of benign lesions of the bile ducts even in young patients in need of a long-term biliary bypass.
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Affiliation(s)
- M A Röthlin
- Department of Surgery, Zürich University Hospital, Switzerland
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Nemcek AA. Gastrointestinal Interventions: Current Concepts and Future Directions. J Vasc Interv Radiol 1996. [DOI: 10.1016/s1051-0443(96)70083-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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