Comparison of technical success and complications of percutaneous transhepatic cholangiography and biliary drainage between patients with and without transplanted liver. AJR Am J Roentgenol. 2012;199:1149-1152. [PMID: 23096192 DOI: 10.2214/AJR.11.8281]

Iatrogenic vascular complications of non-vascular percutaneous abdominal procedures

PURPOSE

The purpose of this paper is to compile and present all of the reported vascular complications that resulted from common non-vascular abdominal procedures in the literature. Non-vascular procedures include, though are not limited to, percutaneous abscess/fluid collection drainage (PAD), percutaneous nephrostomy (PN), paracentesis, percutaneous transhepatic cholangiography (PTC)/percutaneous biliary drainage (PBD), percutaneous biliary stone removal, and percutaneous radiologic gastrostomy (PG)/percutaneous radiologic gastrojejunostomy (PG-J). By gathering this information, radiologists performing these procedures can be aware of the associated vascular injuries, as well as take steps to minimize risks.

METHODS

A literature review was conducted using the PubMed database to catalog relevant articles, published in the year 2000 onward, in which an iatrogenic vascular complication occurred from the following non-vascular abdominal procedures: PAD, PN, paracentesis, PTC/PBD, percutaneous biliary stone removal, and PG/PG-J. Biopsy and tumor ablation were deferred from this article.

RESULTS

214 studies met criteria for analysis. 28 patients died as a result of vascular complications from the analyzed non-vascular abdominal procedures. Vascular complications from paracentesis were responsible for 19 patient deaths, followed by four deaths from PTC/PBD, three from biliary stone removal, and two from PG.

CONCLUSION

Despite non-vascular percutaneous abdominal procedures being minimally invasive, vascular complications still can arise and be quite serious, even resulting in death. Through the presentation of vascular complications associated with these procedures, interventionalists can improve patient care by understanding the steps that can be taken to minimize these risks and to reduce complication rates.

Percutaneous Biliary Interventions via the Modified Hutson Loop in Patients with Biliary-Enteric Anastomoses: A Retrospective Study

PURPOSE

This study aimed to present the institutional experience and algorithm for performing biliary interventions in liver transplant patients using the modified Hutson loop access (MHLA) and the impact of percutaneous endoscopy via the MHLA on these procedures.

METHODS

Over 13 years, 201 MHLA procedures were attempted on 52 patients (45 liver transplants; 24 living and 21 deceased donors) for diagnostic (e.g., cholangiography) and therapeutic (e.g., stent/drain insertion and cholangioplasty) purposes. The most common indications for MHLA were biliary strictures (60%) and bile leaks (23%). Percutaneous endoscopy was used to directly visualize the biliary-enteric anastomosis, diagnose pathology (e.g., ischemic cholangiopathy), and help in biliary hygiene (removing debris/casts/stones/stents) in 138/201 (69%) procedures. Technical success was defined as cannulating the biliary-enteric anastomosis and performing diagnostic/therapeutic procedure via the MHLA.

RESULTS

The technical success rate was 95% (190/201). The failure rate among procedures performed with and without endoscopy was 2% (3/138) versus 13% (8/63) (P = 0.0024), and the need for new transhepatic access (to aid the procedure) was 12% (16/138) versus 30% (19/63) (P = 0.001). Despite endoscopy, failure in 2% of the cases resulted from inflamed/friable anastomosis (1/3) and high-grade stricture (2/3) obstructing retrograde cannulation of biliary-enteric anastomosis. Major adverse events (bowel perforation and injury) occurred in 1% of the procedures, with no procedure-related mortality.

CONCLUSIONS

MHLA-based percutaneous biliary intervention is a safe and effective alternative to managing complications after liver transplant. Percutaneous endoscopy via the MHLA improves success rates and may reduce the need for new transhepatic access. Level of Evidence Level 4.

Risk factors for recurrent stenosis after balloon dilation for benign hepaticojejunostomy anastomotic stricture

BACKGROUND/AIMS

Hepaticojejunostomy anastomotic stricture (HJAS) is a feared adverse event associated with hepatopancreatobiliary surgery. Although balloon dilation for benign HJAS during endoscopic retrograde cholangiopancreatography with balloon-assisted enteroscopy has been reported to be useful, the treatment strategy remains controversial. Therefore, we evaluated the outcomes and risk factors of recurrent stenosis after balloon dilation alone for benign HJAS.

METHODS

We retrospectively analyzed consecutive patients who underwent balloon-assisted enteroscopy-endoscopic retrograde cholangiopancreatography for benign HJAS at our institution between July 2014 and December 2020.

RESULTS

Forty-six patients were included, 16 of whom had recurrent HJAS after balloon dilation. The patency rates at 1 and 2 years after balloon dilation were 76.8% and 64.2%, respectively. Presence of a residual balloon notch during balloon dilation was an independent predictor of recurrence (hazard ratio, 2.80; 95% confidence interval, 1.01-7.78; p=0.048), whereas HJAS within postoperative 1 year tended to be associated with recurrence (hazard ratio, 2.43; 95% confidence interval, 0.85-6.89; p=0.096). The patency rates in patients without a residual balloon notch were 82.1% and 73.1% after 1 and 2 years, respectively.

CONCLUSION

Balloon dilation alone may be a viable option for patients with benign HJAS without residual balloon notches on fluoroscopy.

Outcomes of endoscopic retrograde cholangiography and percutaneous transhepatic biliary drainage in liver transplant recipients with a Roux-en-Y biliary-enteric anastomosis

Backgrounds/Aims

Data regarding outcomes of endoscopic retrograde cholangiography (ERC) in liver transplant (LT) recipients with biliary-enteric (BE) anastomosis are limited. We report outcomes of ERC and percutaneous transhepatic biliary drainage (PTBD) as first-line therapies in LT recipients with BE anastomosis.

Methods

All LT recipients with Roux-BE anastomosis from 2001 to 2020 were divided into ERC and PTBD subgroups. Technical success was defined as the ability to cannulate the bile duct. Clinical success was defined as the ability to perform cholangiography and therapeutic interventions.

Results

A total of 36 LT recipients (25 males, age 53.5 ± 13 years) with Roux-BE anastomosis who underwent biliary intervention were identified. The most common indications for a BE anastomosis were primary sclerosing cholangitis (n = 14) and duct size mismatch (n = 10). Among the 29 patients who initially underwent ERC, technical success and clinical success were achieved in 24 (82.8%) and 22 (75.9%) patients, respectively. The initial endoscope used for the ERC was a single balloon enteroscope in 16 patients, a double balloon enteroscope in 7 patients, a pediatric colonoscope in 5 patients, and a conventional reusable duodenoscope in 1 patient. Among the 7 patients who underwent PTBD as the initial therapy, six (85.7%) achieved technical and clinical success (p = 0.57).

Conclusions

In LT patients with Roux-BE anastomosis requiring biliary intervention, ERC with a balloon-assisted enteroscope is safe with a success rate comparable to PTBD. Both ERC and PTBD can be considered as first-line therapies for LT recipients with a BE anastomosis.

Outcomes of patients with hepaticojejunostomy anastomotic strictures undergoing endoscopic and percutaneous treatment

Background and study aims  The increase in hepaticojejunostomies has led to an increase in benign strictures of the anastomosis. Double balloon enteroscopy-assisted ERCP (DBE-ERCP) and percutaneous transhepatic biliary drainage (PTBD) are treatment options; however, there is lack of long-term outcomes, with no consensus on management. We performed a retrospective study assessing the outcomes of patients referred for endoscopic management of hepaticojejunostomy anastomotic strictures (HJAS). Patients and methods  All consecutive patients at a tertiary institution underwent endoscopic intervention for suspected HJAS between 2009 and 2021 were enrolled. Results  Eighty-two subjects underwent DBE-ERCP for suspected HJAS. The technical success rate was 77 % (63/82). HJAS was confirmed in 41 patients. The clinical success rate for DBE-ERCP ± PTBD was 71 % (29/41). DBE-ERCP alone achieved clinical success in 49 % of patients (20/41). PTBD was required in 49 % (20/41). Dual therapy was required in 22 % (9/41). Those with liver transplant had less technical success compared to other surgeries (72.1 % vs 82.1 % P  = 0.29), less clinical success with DBE-ERCP alone (40 % vs 62.5 % P  = 0.16) and required more PTBD (56 % vs 37.5 % P  = 0.25). All those with ischemic biliopathy (n = 9) required PTBD for clinical success, required more DBE-ERCP (4.4 vs 2.0, P = 0.004), more PTBD (4.7 vs 0.3, P  < 0.0001), longer treatment duration (181.6 vs 99.5 days P  = 0.12), and had higher rates of recurrence (55.6 % vs 30.3 % P  = 0.18) compared to those with HJAS alone. Liver transplant was the leading cause of ischemic biliopathy (89 %). The overall adverse event rate was 7 %. Conclusions  DBE-ERCP is an effective diagnostic and therapeutic tool in those with altered gastrointestinal anatomy and is associated with low complication rates.

[Biliary system interventions : Percutaneous transhepatic cholangiodrainage to bilioma]

BACKGROUND

A variety of transhepatic percutaneous biliary procedures are appropriate for the treatment of pathologies of the biliary system.

OBJECTIVES

The aim of this article is to describe best practices for performing percutaneous transhepatic cholangiography with placement of a biliary drain (PTCD), percutaneous transhepatic removal of bile duct stones, percutaneous stenting of the bile ducts, and percutaneous treatment of postoperative bilioma.

MATERIALS AND METHODS

The authors reviewed existing literature on relevant current recommendations and presented them based on their own facility's approach.

RESULTS

Biliary interventions are mostly aimed at treating some form of cholestasis of benign or malignant etiology. The technical success rate is up to 90%.

CONCLUSION

Percutaneous biliary interventions are safe and effective procedures in the treatment of pathologies of the biliary system, preferably used when endoscopic access is not possible due to anatomical conditions.

Percutaneous transhepatic biliary drainage: a retrospective single-center study of 372 patients

BACKGROUND

Complication rates in percutaneous transhepatic biliary drainage (PTBD) are non-uniform and vary considerably. In addition, the impact of peri-procedural risk factors is under-investigated.

PURPOSE

To compare success and complication rates of PTBD in patients with and without accompanying technical risk factors.

MATERIAL AND METHODS

A single-center retrospective study was conducted from January 2004 to December 2016. Patients receiving PTBD due to biliary obstruction or biliary leakage were included. Technical risk factors (non-distended bile ducts, ascites, obesity, anasarca, non-compliance) were assessed. Complications were classified according to the Society of Interventional Radiology.

RESULTS

In total, 372 patients were included (57.3% men, 42.7% women; mean age = 66 years). Overall, 466 PTBDs were performed. Of the patients, 70.1% presented with malignancy and biliary obstruction; 26.8% had benign biliary obstruction; 3.1% had biliary leakage. Technical risk factors were reported in 57 (15.3%) patients. Overall technical success of initial PTBD was 98.7%, primary technical success was 97.9%. In patients with non-dilatated bile ducts, primary technical success was 68.2%. Overall complication rate was 15.0% (8.1% major complications, 6.9% minor complications). Neither major nor minor complications were more frequent in patients with technical risk factors (P > 0.05). In left-sided PTBD, hemorrhage was more frequent (P = 0.015). Patients with malignancy were significantly more affected by drainage-related complications (P = 0.004; odds ratio = 2.03). The mortality rate was 0.5% (n = 2).

CONCLUSION

PTBD is a safe and effective method for the treatment of biliary obstruction and biliary leaks. Complication rates are low, even in procedures with risk factors.

The experience of use of percutaneous transhepatic biliary drainages for early biliary complications after liver transplantation

This study aimed to describe our experience and discuss the results, controversies, and the use of percutaneous transhepatic biliary drainage (PTBD) in patients with biliary complications after liver transplantation (LT). Between November 2009 and August 2020, 76 consecutive patients who underwent 77 LTs (44 deceased donor LTs and 33 living donor LTs [LDLT]) were enrolled retrospectively. Endoscopic therapy as initial approach and PTBD as rescue therapy were used for patients with biliary complications. There were 31 patients (31/76, 40.8%) with biliary complications, and two of them died (2/31, 6.5%). Clinical success rate of endoscopic therapy alone was 71.0% (22/31). The remaining nine patients received salvage PTBD and their clinical results were observed according to whether their intrahepatic bile ducts (IHBDs) was dilated (group A, n = 5) or not (group B, n = 4). In group A, the technical and long-term clinical success rates of PTBD were 100% and 20%, respectively. These five patients received PTBD ranging from 75 to 732 days after their LTs, and no procedure-related complications were encountered. In group B, the technical and long-term clinical success rates of PTBD were 50% and 25%, respectively. Three group B patients (75%) underwent PTBD within 30 days after LDLT and had lethal complications. One patient had graft laceration and survived after receiving timely re-transplantation. The other two patients died of sepsis due to PTBD-related bilioportal fistula or multiple liver abscesses. Our experience showed salvage PTBD played a limited role in biliary complications without dilated IHBDs within 1 month after LT.

Total Fluoroscopy Time Reduction During Ultrasound- and Fluoroscopy-Guided Percutaneous Transhepatic Biliary Drainage Procedure: Importance of Adjusting the Puncture Angle

BACKGROUND The purpose of this observational cohort study was to assess patient and operator-dependent factors which could have an impact on total fluoroscopy time during ultrasound and fluoroscopy-guided percutaneous transhepatic biliary drainage (PTBD). MATERIAL AND METHODS Between October 2016 and November 2020, 127 patients with malignant biliary obstruction underwent ultrasound- and fluoroscopy-guided PTBD with the right-sided intercostal approach. The initial bile duct puncture was ultrasound-guided in all patients, and the puncture angle was measured by ultrasound. Any subsequent steps of the procedure were performed under continuous fluoroscopy (15 fps). The patients were divided in 2 groups based on the puncture angle: ≤30° (group I) and >30° (group II). In a retrospective analysis, both groups were compared for inter- and intragroup variability, technical success, total fluoroscopy time, and complications. RESULTS In group II, the recorded total fluoroscopy time (232.20±140.94 s) was significantly longer than that in group I (83.44±52.61 s) (P<0.001). In both groups, total fluoroscopy time was significantly longer in cases with a lesser degree of bile duct dilatation, intrahepatic bile duct tortuosity, presence of liver metastases, and multiple intrahepatic bile duct strictures. CONCLUSIONS The initial bile duct puncture angle was identified as an operator-dependent factor with the possible impact on total fluoroscopy time. The puncture angle of less than 30° was positively correlated with overall procedure efficacy and total fluoroscopy time reduction.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

Future Directions of Percutaneous Biliary Interventions

We are at an exciting cross-road in biliary interventions. While other services such as surgery and gastroenterology have learned to use imaging guidance to improve the safety and efficacy of their procedures, it is time for interventional radiologist to learn endoscopic interventions to achieve the same. The future of interventional radiologists in managing patients with biliary disease depends on (1) increasing comfort of our procedures, (2) publishing our data on biliary interventions, and (3) increasing collaboration with other services to manage biliary disease. We need to appropriately understand the limitations of interventional radiology to help guide the future directions of our specialty in this very interesting space.

CIRSE Standards of Practice on Percutaneous Transhepatic Cholangiography, Biliary Drainage and Stenting

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

Percutaneous Access of the Modified Hutson Loop for Retrograde Cholangiography, Endoscopy, and Biliary Interventions

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.

Percutaneous-transhepatic-endoscopic rendezvous procedures are effective and safe in patients with refractory bile duct obstruction

Background

Percutaneous-transhepatic-endoscopic rendezvous procedures (PTE-RVs) are rescue approaches used to facilitate biliary drainage.

Objective

The objective of this article is to evaluate the safety and the technical success of PTE-RVs in comparison with those of percutaneous transhepatic cholangiographies (PTCs).

Methods

Percutaneous procedures performed over a 10-year period were retrospectively analyzed in a single-center cohort. Examinations were performed because of a previous or expected failure of standard endoscopic methods including endoscopic retrograde cholangiography (ERC) or balloon-assisted ERC to achieve biliary access.

Results

In total, 553 percutaneous procedures including 163 PTE-RVs and 390 PTCs were performed. Overall, 71.3% of the patients suffered from malignant disease with pancreas-carcinoma (32.8%) and cholangio-carcinoma (19.0%) as the most frequent, while 28.7% of the patients suffered from benign disease. Many patients had a postoperative change in bowel anatomy (50.8%).PTC had a higher technical success rate (89.7%); however, the technical success rate of PTE-RVs was still high (80.4%; p < 0.003). Overall complications occurred in 23.5% of all procedures. Significantly fewer complications occurred after performing PTE-RVs than after PTCs (16.6% vs 26.4%; p = 0.037).

Conclusion

Beside a high technical efficacy of PTE-RVs, significantly fewer complications occur following PTE-RVs than following PTCs; thus, PTE-RV should be preferred over PTC alone in selected patients.

Percutaneous Transjejunal Biliary Access in 60 Patients with Bilioenteric Anastomoses

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.

Added value of gadoxetic acid-enhanced T1-weighted magnetic resonance cholangiography for the diagnosis of post-transplant biliary complications

OBJECTIVES

Biliary complications after liver transplantation (LT) are common. This study aimed to ascertain the value of gadoxetic acid-enhanced T1-weighted (T1w) magnetic resonance cholangiography (MRC) to evaluate anastomotic strictures (AS), non-anastomotic strictures (NAS) and biliary casts (BC).

METHODS

Sixty liver-transplanted patients with suspicion of biliary complications and T2w-MRCP and T1w-MRC followed by endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) were analysed. Two readers reviewed the MRCs and rated image quality (IQ) and likelihood for AS/NAS/BC on Likert scales. Sensitivity, specificity and predictive values were calculated, ROC curve analysis performed, and inter-reader variability assessed. The subjective added value of T1w-MRC was rated.

RESULTS

IQ was high for all sequences without significant differences (2.83-2.88). In 39 patients ERCP/PTC detected a complication. Sensitivity and specificity for AS were 64-96 using T2w-MRCP, increasing to 79-100 using all sequences. Use of all sequences increased the sensitivity of detecting NAS/BC from 72-92% to 88-100% and 67-89% to 72-94%, respectively. Kappa values were substantial (0.45-0.62). T1w-MRC was found to be helpful in 75-83.3%.

CONCLUSIONS

Combining T1w-MRC and T2w-MRCP increased sensitivity and specificity and diagnostic confidence in patients after LT with suspected biliary complications. T1w-MRC is a valuable tool for evaluating post-transplant biliary complications.

KEY POINTS

• T1w-MRC is a valuable tool for evaluating post-transplant biliary complications. • Adding T1w-MRC to T2w-MRC increases diagnostic confidence for detection of biliary complications. • A combination of T1w-MRC and T2w-MRCP leads to the best results.

[Antegrade endobiliary interventions in undilated bile ducts]

AIM

To show advisability of antegrade transhepatic approach to bile ducts for benign and malignant biliary diseases if endoscopic technique is impossible or ineffective.

MATERIAL AND METHODS

38 patients underwent external biliary drainage followed by endobiliary interventions for the period 2009-2016.

RESULTS

In all patients treatment was effective and included following manipulations: antegrade balloon dilatation of stricture of biliodigestive anastomosis, papillodilatation, antegrade dislocation of calculuses from common bile duct to duodenum. There were 2 cases of complications after antegrade interventions. 1 woman died from severe pancreatic necrosis.

CONCLUSION

Percutaneous transhepatic cholangiostomy on undilated bile ducts is effective for temporary biliary drainage in closure of external duodenal or biliary fistula, treatment of intra-abdominal bilema. The method is indicated in elective endobiliary interventions for choledocholithiasis management, elimination of stricture of biliodigestive anastomosis of major duodenal papilla if endoscopic or conventional approaches are impossible or ineffective.

Similar Efficacies of Endoscopic Ultrasound-guided Transmural and Percutaneous Drainage for Malignant Distal Biliary Obstruction

BACKGROUND & AIMS

Although percutaneous transhepatic biliary drainage (PTBD) is the standard method for draining a malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatographies (ERCPs), use of endoscopic ultrasound-guided transmural biliary drainage (EUS-BD) is increasing. We performed a multicenter, open-label, randomized trial to compare EUS-BD vs PTBD for malignant distal biliary obstruction after a failed ERCP.

METHODS

Patients with unresectable malignant distal biliary obstructions and failed primary ERCP, caused by inaccessible papilla, were assigned to groups that underwent EUS-BD with an all-in-one device for direct deployment of a partially covered metal stent (without further fistula tract dilation, n = 34) or PTBD (n = 32). The procedures were performed at 4 tertiary academic referral centers in South Korea from October 2014 through March 2015; patients were followed up through June 2015. The primary end point was technical success, which was calculated using a noninferiority model. Secondary end points were functional success, procedure-related adverse events, rate of unscheduled re-intervention, and quality of life (QOL).

RESULTS

The rates of primary technical success were 94.1% (32 of 34) in the EUS-BD group and 96.9% (31 of 32) in the PTBD group (1-sided 97.5% confidence interval lower limit, -12.7%; P = .008 for a noninferiority margin of 15%). The rates of functional success were 87.5% (28 of 32) in the EUS-BD group and 87.1% (27 of 31) in the PTBD group (P = 1.00). The proportions of procedure-related adverse events were 8.8% in the EUS-BD group vs 31.2% in the PTBD group (P = .022); the mean frequency of unscheduled re-intervention was 0.34 in the EUS-BD group vs 0.93 in the PTBD group (P = .02). The QOL was similar between groups.

CONCLUSIONS

EUS-BD and PTBD had similar levels of efficacy in patients with unresectable malignant distal biliary obstruction and inaccessible papilla based on rates of technical and functional success and QOL. However, EUS-BD produced fewer procedure-related adverse events and unscheduled re-interventions. Clinical trial registration no: cris.nih.go.kr/KCT0001370.

Peripheral portal vein-oriented non-dilated bile duct puncture for percutaneous transhepatic biliary drainage

AIM: To evaluate the efficacy of peripheral portal vein (PV)-oriented non-dilated bile duct (BD) puncture for percutaneous transhepatic biliary drainage (PTBD).

METHODS: Thirty-five patients with non-dilated BDs underwent PTBD for the management of various biliary disorders, including benign bilioenteric anastomotic stricture (n = 24), BD stricture (n = 5) associated with iatrogenic BD injury, and postoperative biliary leakage (n = 6). Under ultrasonographic guidance, percutaneous transhepatic puncture using a 21-G needle was performed along the running course of the peripheral targeted non-dilated BD (preferably B6 for right-sided approach, and B3 for left-sided approach) or along the accompanying PV when the BD was not well visualized. This technique could provide an appropriate insertion angle of less than 30° between the puncture needle and BD running course. The puncture needle was then advanced slightly beyond the accompanying PV. The needle tip was moved slightly backward while injecting a small amount of contrast agent to obtain the BD image, followed by insertion of a 0.018-inch guide wire (GW). A drainage catheter was then placed using a two-step GW method.

RESULTS: PTBD was successful in 33 (94.3%) of the 35 patients with non-dilated intrahepatic BDs. A right-sided approach was performed in 25 cases, while a left-sided approach was performed in 10 cases. In 31 patients, the first PTBD attempt proved successful. Four cases required a second attempt a few days later to place a drainage catheter. PTBD was successful in two cases, but the second attempt also failed in the other two cases, probably due to poor breath-holding ability. Although most patients (n = 26) had been experiencing cholangitis with fever (including septic condition in 8 cases) before PTBD, only 5 (14.3%) patients encountered PTBD procedure-related complications, such as transient hemobilia and cholangitis. No major complications such as bilioarterial fistula or portal thrombosis were observed. There was no mortality in our series.

CONCLUSION: Peripheral PV-oriented BD puncture for PTBD in patients with non-dilated BDs is a safe and effective procedure for BD stricture and postoperative bile leakage.

Ethylene-vinyl alcohol copolymer endobiliary obliteration of hepatic segments in a patient with isolated bile leaks

A 54-year-old woman with a symptomatic giant hepatic hemangioma underwent an extended left hepatic trisegmentectomy complicated by 250-350 mL/d postoperative bilious drainage. After 5 months of therapy, drainage was unabated, and the patient was no longer a surgical candidate. Sinography revealed three distinct isolated bile duct leaks involving segments 6, 7, and 8. Endobiliary segmentectomy was achieved by obliterating the isolated systems with ethylene-vinyl alcohol copolymer (Onyx; ev3, Plymouth, Minnesota) during three fluoroscopic procedures. Bilious leaks were successfully eliminated, and compensatory hypertrophy of noninvolved liver occurred. At 2 years from the last embolization procedure, the patient remained asymptomatic with no bilious leak.