Elsevier

Clinical Radiology

Volume 71, Issue 12, December 2016, Pages 1312.e7-1312.e11
Clinical Radiology

A review of percutaneous transhepatic biliary drainage at a tertiary referral centre

https://doi.org/10.1016/j.crad.2016.05.013Get rights and content

Highlights

  • Our study demonstrated significantly lower morbidity and mortality compared with BSIR audit.

  • However major complications associated with mortality were more or less the same.

  • This is likely related to the strict pre- & post-procedural optimisation.

  • Our protocol is based on quality improvement guidelines from CIRSE.

  • Implementation of CIRSE practice guidelines decreases PTBD morbidity and mortality.

Aim

To review percutaneous biliary drainage (PBD) procedures performed in Beaumont Hospital, Dublin, Ireland, over a 6-year period, to determine the 30-day morbidity and mortality.

Materials and methods

A total of 119 patients undergoing 193 PBD procedures were identified over a 6 year period. Of the patients, 6.7% (eight patients) had stone disease, 63% (75 patients) had a malignancy, and the remainder were diagnosed with other conditions. Standard techniques of PBD and biliary stent insertion were applied, with 73 patients (61%) having same-day procedures and all undergoing gelfoam embolisation of percutaneous tracts. All patients received intravenous prophylactic antibiotics and intravenous hydration prior to PBD.

Results

The technical success rate was 97%, with a mean drop of 105 mmol/l between pre- and post-procedure bilirubin. Thirty-day mortality was 10.9% (13 deaths), with major and minor morbidities of 5% (six patients) and 7.6% (nine patients), respectively. Major complications included sepsis in two patients, major haemorrhage in two patients, and renal failure in two patients. Minor complications included infection in seven patients, bile leak causing self-limiting pain in one patient, and minor haemorrhage in one patient.

Conclusion

The study confirms that PBD and stent insertion is a safe and effective technique in Beaumont Hospital, associated with an overall acceptable morbidity and mortality comparable with other studies.

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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