PERCUTANEOUS TRANSHEPATICCHOLANGIOGRAPHY ANDBILIARY INTERVENTION

Indications

Treatment of malignant obstruction Adjunct to surgery Treatment of CBD calculi Treatment of benign strictures Diagnostic? Failed ERCP

Patient selection

WHO performance status Imaging Clinician/MDT discussion Coagulation status Ascites

WHO performance status

0 – 2. In bed less than 50% of time BSIR Audit report 2009, 19.8% in hospital

mortality 15.6% in hospital mortality for benign

disease Audit of my procedures, 18% 30 day

mortality Patients with lower WHO performance

status do better

Imaging

Ultrasound. Confirm biliary obstruction, mass, metastatic disease, calculi

CT. Confirm level of obstruction, mass, metastatic disease

MRI/MRCP. Complex biliary strictures, CBD calculi, liver metastases

ERCP. May have failed

Clinician/MDT discussion

Malignant or benign disease Gastroenterologists Surgeons Radiologists Other Healthcare Workers

Malignant Disease

Surgical. ERCP and plastic stent or PTC and Internal/External biliary drainage

Palliative. ERCP or PTC and metallic Stent

Benign Disease

ERCP treatment of choice PTC and internal/external drain or plastic

stent. May enable successful ERCP later

Coagulation status

INR < 1.4. Consider vitamin K, FFP and also Beriplex/Octaplex. Contain prothrombin complex concentrate. Factors II, VII, IX and X as well as Proteins C and S

Platelets > 100,000. If less, consider platelet transfusion

Consent

WHO performance status Check coagulation Explain procedure at least 1 day before Risks. Bleeding, bile leak, infection,

pneumothorax and failure

Anaesthetic

Anaesthetist GA Discuss need for airway protection Use LA When applying for consultant post ask

what access you may have to anaesthetics

Antibiotics

At start of procedure Gentamicin 240 mg IV Metronidazole 500 mg IV Discuss with Microbiology

Equipment

Use what works best for you Chiba needle 22 gauge Trochar needle 18 gauge NEF set Stiff Terumo wire Amplatz wire Catheters. BMC and straight Self expanding stent Internal/External drains 8.5/10.5F. Discuss

with your surgeon

Approach/Technique 1

Ascites present? Drain first Ultrasound? Right lobe. Mid axillary line. Aim for xyphisternum. Left lobe. Locate with U/S and usually aim for

segment III. Very gently inject 1/3 strength contrast (100) as

needle is withdrawn Duct entered when contrast flows away from

needle and persists Duct not entered. Change angle and try not to exit

liver capsule Duct normally anterior to portal vein

Approach/Technique 2

Pre-surgery for cholangiocarcinoma. Discuss lobe to drain. Usually the lobe being preserved.

Pre-surgery for pancreatic cancer. Right lobe puncture.

Palliative. Drain right, left or both? 1. Chiba needle to opacify ducts then choose

duct for trochar puncture and wire etc. 2. NEF set. Single puncture then wire, dilator

and access sheath Consider bile for cytology if no diagnosis

Approach/Technique 3

Stiff Terumo to cross lesion. Use pin vice for torque

Straight catheter Amplatz wire Dilator Stent/Drain 1 or 2 stage procedure? Temporary drain following stent? Plug track? Coils, gelfoam etc. Technical success >95% (BSIR audit)

Approach/Technique 4

Unable to cross stricture, establish external drainage (8.5F internal/external drain). Further attempt after decompression usually successful.

Care with drainage bag essential. Internal external drainage, try not to use

bag and bung catheter.

BSIR Audit. Mortality & Complications (reported)

In hospital mortality 19.8%. Death or major complication 21.2% overall, 18.3%

benign, 21.7% malignant. Major complications in 7.9%, haemorrhage 3.5%,

renal failure 1.8% and sepsis 1.6%. Minor complications in 26.0%, pain 14.3%, sepsis

7.7% and haemorrhage 4.5%. Association with ascites, elevated INR and low

platelets. 1 year survival <20% for malignant disease. Drainage more effective if stents placed across

ampulla

BSIR recommendations

1. Further audit of this cohort is required to determine cause of death and to demonstrate whether or not there are significant associated risk factors.

2. Given the high mortality in this group of patients further data collection will be required. Significant improvements in data completeness are required. Data submission remains voluntary, but NHS services should consider how they can make resources available to support data collection for individual operators

Case 1

86 yr female presented with sepsis and subsequent jaundice

Arteriopath but otherwise reasonably fit CT

Case 1

Abscess right lobe liver drained Antibiotics MDT discussion, for palliation ERCP, failed to stent due to large

duodenal diverticulum PTC

Case 2

69 yr male with obstructive jaundice CT, operable mass in head of pancreas MDT discussion Surgical candidate ERCP to place plastic stent failed PTC

Case 3

75 yr female with obstructive jaundice CT, large central liver mass, likely

cholangiocarcinoma. Further deposit in segment II

MDT discussion, not operable, palliative PTC and stent left lobe

Case 4

71 yr male Metastatic colorectal cancer Multiple liver resections Jaundice with recurrent liver and

peritoneal tumour Considering further chemotherapy CT Small residual liver with mild duct

dilatation ERCP failed

Case 5

59 yr female with inoperable cholangiocarcinoma

Previous ERCPs with plastic and finally recently metal stent into left lobe

Recurrent jaundice ?percutaneous options

Take Home Points

Careful patient selection after MDT discussion

“Appropriate” Anaesthesia Try not to use external drainage bags