A review of percutaneous transhepatic biliary drainage at a tertiary referral centre
Introduction
Biliary obstruction may be due to benign, malignant, or iatrogenic diseases. The most common malignant cause of biliary obstruction is an underlying pancreatic neoplasm extrinsically compressing the distal bile duct. Other conditions include cholangiocarcinoma, as well as metastatic disease at the hepatic hilar nodes or in the peri-pancreatic nodes, causing obstructive jaundice from extrinsic pressure on the proximal or distal portions of the biliary tree.1, 2, 3 Benign diseases include inflammatory processes and stones as well as rare conditions, e.g., Mirizzi's syndrome, along with benign tumours and iatrogenic or traumatic biliary injuries.4, 5, 6, 7
A great majority of patients with biliary obstruction, in particular due to pancreatic neoplasms or stone disease, can be treated by endoscopic retrograde cholangiopancreatography (ERCP); however, those who fail ERCP, may require percutaneous transhepatic biliary drainage (PTBD) to achieve adequate biliary decompression.1, 2
PTBD is an effective method for the management of biliary abnormalities under imaging guidance using interventional radiology techniques, which involves sterile cannulation of a peripheral bile duct followed by guidewire and catheter positioning above the stricture.8, 9 Subsequently, contrast material injection into an intra-hepatic bile duct will provide a cholangiogram, delineating the anatomy of the biliary tree, determining the location of obstruction, and helping to guide the intervention.2, 9
Depending on the cholangiographic findings, placement of a catheter or stent may be considered to facilitate internal or external drainage of bile, allowing decompression of the biliary system.1, 2, 10
Apart from the primary underlying cause and the level of the biliary obstruction, different technical aspects of the interventional procedure, including the access, internal versus external biliary drainage, position and type of stent, tract embolisation and duration of drainage have all been investigated as factors that may influence the outcome of the percutaneous biliary drainage (PBD).11
PTBD is effective at relieving biliary obstruction; however, it has been associated with complications including sepsis, haemorrhage and localised infective, as well as inflammatory processes such as abscess, peritonitis, cholecystitis, and pancreatitis,2, 12 with an overall 30-day in hospital mortality rate of approximately 20% in one recent study.13, 14
The aim of the present study was to review PTBDs performed in a tertiary referral centre, Beaumont Hospital, Dublin, Ireland, and to assess technical success and 30 day morbidity and mortality rates.
Section snippets
Materials and methods
As a retrospective audit, this study did not require approval from the institution's ethics committee.
Results
On the pre-procedural imaging work-up it was shown that 43 patients (37%) suffered from cholelithiasis, choledocholithiasis, pancreatitis, and cholangitis or related complications, 75 patients (63%) had a malignant neoplastic condition, with 37/75 (49%) having a primary biliary, pancreatic, or hepatocellular malignancy; while the remainder were diagnosed with metastatic conditions (Electronic Supplementary Material, Table S1).
Technical success was defined as the ability to complete all
Discussion
Most studies have shown that PTBD has a high technical success rate, with one recent study demonstrating a success rate >95%, but with a high 30-day mortality rate of 19.8% and significant morbidity of 34%.13 In comparison, in the present study, significantly lower mortality and morbidity rates of 10.9% and 12.6%, respectively, were demonstrated. The recent BSIR audit also reported that haemorrhage, sepsis, and renal failure were the most common major complications associated with the highest
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