Interventional radiology (percutaneous treatment) in bile duct obstructions

Interventional Radiology in Biliary Tract Obstructions

In patients presenting to the physician with obstructive jaundice (obstructive icterus), the “cause” of the obstruction should be investigated first. After the cause is determined, a “treatment” plan should be established. In obstructive jaundice, the Radiology department plays an important role both in determining the cause and in its treatment.

The most common causes of Bile Tract Obstruction are:

Stones and tumors. Among the tumors (cancers), the most common biliary tract cancer (cholangiocarcinoma), pancreatic cancer, gallbladder cancer, ampullary cancer, metastatic (spread elsewhere) cancers are included. Apart from this, previous surgeries, some parasites, and lymph node diseases can also cause jaundice by blocking the bile duct.

Symptoms in Bile Tract Obstruction:

Jaundice (on the sclera and skin)

Stomach ache

Loss of appetite, weight loss

Chills-chills-fever (cholangitis)

Itching

darkening of urine color

Fading in stool color

Laboratory Findings in Biliary Tract Obstruction:

Blood : Bilirubin increase (direct weight), LFT disorder (AST, ALT, GGT)

Urine: Bilirubin (+) increase

Stool: Decreased stercobilinogen

Radiological Imaging in Biliary Tract Obstruction:

Ultrasonography (USG) : It is the first applied method. It is used to detect the presence, level and etiology of cholestasis. If tumor-related obstruction is considered, advanced imaging methods (CT and/or MRI) are used.

Computed Tomography (CT) : It is applied if bile duct obstruction is due to tumor. The tumor is tried to be shown with dynamic and multiphasic CT examination. At the same time, the surgical resectability of the tumor is determined by CT.

MR/MRCP : In addition to the information given by CT, MR-cholangiographic images are obtained. It helps with the treatment plan.

Percutaneous Transhepatic Cholangiography (PTC) : It is a direct cholangiographic method. It is the most precise imaging method in determining the etiology of bile duct obstructions. It also constitutes the first step of percutaneous biliary interventions (stent, balloon, catheter drainage, stone removal, etc.)

Interventional Radiological Procedures in Biliary Tract Obstruction:

one. Imaging-Guided Needle Biopsy: It is used to obtain pathological diagnosis in malignant biliary obstruction. It is usually performed as Fine Needle Aspiration Biopsy (FNAB) in pancreatic carcinomas. In biliary tract tumors (cholangiocarcinoma, gallbladder cancer, ampullary carcinoma, etc.), the bile ducts are entered by percutaneous transhepatic route and performed as Endoluminal Forceps Biopsy (ELFB).

2. Bile Duct Stent Implantation:

Since resectability is not possible in 85-90% of malignant bile duct obstructions, there is no chance of surgical treatment. In addition, since these tumors are seen in advanced ages, there are additional risk factors (cardiovascular, pulmonary, etc.) and some of the patients are not operable even if they are resectable. For this reason, up to 90% of patients receive palliative treatments. The most important in the treatment of patients opening of the blocked bile duct by placing a stentprocess.

Stent placement in the biliary tract is performed by “Endoscopic” and “Percutaneous” ways. In both ways, the aim is to “flow the bile into the intestine”. However, Percutaneous Metallic biliary stents have many advantages over Endoscopic Plastic biliary stents.

Comparisons of Percutaneous and Endoscopic stentscan be done like this:

Percutaneously placed metallic stents remain open longer than endoscopically placed plastic stents. Because the lumen diameter of metallic stents is 3-5 times wider than the lumen of plastic stents, and therefore, the probability of occlusion of the metallic stent is much less.

Metallic stents are self-expandible. When closed (outside) their diameter is 7 Fr (2.3 mm) thick. A 2.3 mm wide tract is sufficient for entry, as it is advanced closed to the place where it will be placed. After reaching the desired place, the stent is opened while it is in place and reaches a diameter of 10 mm. This means minimal trauma and minimal complications when passing stenosis in the percutaneous access tract and within the tumor.

Since metallic stents do not disrupt the drainage of side branches like plastic stents, they provide more effective bile flow in complex occlusions (hilar cholangiocarcinomas with multiple duct occlusions).

Another advantage is that metallic stents do not have the possibility of displacement (migration) thanks to the end teeth embedded in the mucosa. Plastic stents migrate quite frequently.

In metallic stents, there is no infection related to the stent itself, whereas in plastic stents, the stent itself may cause infection, since the lumen is narrow and bile flow is limited. For this reason, plastic stents should be replaced with a new one every 20-25 days. Since there is no infection and related replacement problem in metallic stents, repeated interventions are not possible.

In metallic stents, in case the tumor progresses and occludes the stent, re-opening is easily achieved by placing a new stent in the existing stent or applying radiofrequency to the tumor within the stent via percutaneous endoluminal route. However, in 80-85% of patients, a once placed metallic stent is sufficient throughout the patient’s survival.

After the metallic stents are placed, a multi-hole biliary drainage catheter extending from the stent to the duodenum is placed (instent biliary drainage) and during the first few days the catheter is washed with SF to ensure that the patency of the stent is ensured. In this way, the clot that may occur due to a possible bleeding after the stent is placed, is prevented from occlusion of the stent in the early period. A few days later, a control cholangiogram is taken by administering contrast material through this intra-stent catheter, and after the patency of the stent is assured, the in-stent catheter is removed and the procedure is terminated. There is no such control chance with endoscopic plastic stents.

The most common and serious complication in endoscopic stenting is acute pancreatitis due to the procedure itself. Cannulation of the common bile duct by sphincterotomy and the use of thick (10Fr diameter) endoscopic plastic stents increase this risk. Sometimes, the plastic stent placed in the common bile duct itself blocks the opening of the pancreatic duct, causing pancreatitis. Iatrogenically developing acute pancreatitis, even alone, increases the patient’s morbidity and mortality.

In cases where more than one duct at the hilar level is occluded, drainage can be provided by entering the occluded ducts separately by percutaneous method, but complete drainage of these complex occlusions is not possible by endoscopic method. Even the normal bile duct can be blocked (unintentionally) because the plastic stent, which is placed endoscopically, often extends or migrates to the right or left duct at the level of the hilum, even to open an obstruction at the level of the distal common bile duct.

The only disadvantage of metallic stents compared to plastic stents is that they are approximately 10-12 times more expensive.

Advantage/Disadvantage

Percutaneous Metallic Stent

Endoscopic Plastic Stent

Stent inner diameter

10mm

2-3mm

Stent occlusion

Rare (8-10 months)

Frequent (1-2 months)

Stent slippage

Impossible

Stylish

Stent replacement

Not necessary

every 20-25 days

A. Pancreatitis complex

Rare

Stylish

side branch occlusion

Impossible

Inevitable and frequent

Stent infx and cholangitis

invisible

Stylish

Price

Expensive (18-20 times)

Cheap

3. Celiac Ganglion Blockage:

It is an attempt to relieve or reduce pain in patients with pancreatic cancer (sometimes chronic pancreatitis) that occurs as a result of tumor invasion of the celiac ganglia and does not respond to various analgesic treatments. It is the process of injecting substances that cause neurolysis by entering the celiac ganglion (unilateral or bilateral) with a fine needle under the guidance of Computed Tomography. As the nerve transformer (celiac ganglion) is burned, pain transmission is reduced or absent and the patient is relieved.

My Personal Experiences with Percutaneous Biliary Interventions:

Bile duct stent placement was performed for the first time by us in 1994, in our Çukurova University Medical Faculty Balcalı Hospital Interventional Radiology Department. This initiative, which I started in the second year of my assistantship, gained momentum and lasted by me. in 20 yearsapproximately 16,000 patients A bile duct stent was placed. I have published 3 research articles and 4 case reports in international journals only on percutaneous biliary interventions (a). I have given speeches on this issue at many national meetings (b). Since 2002, I have been working as an editor and referee on hepatobiliary interventions in national and international journals.

(a) My publications on percutaneous biliary interventions :

İnal M , Aksungur E, Akgül E, Oğuz M, Seydaoğlu G. “Percutaneous placement of metallic stents in malignant biliary obstruction: one-stage or two-stage procedure? Pre-dilated or not?”. cardiovasc. Intervent. radiol. 26, 40-45, (2003).

İnal M , Akgül E, Aksungur E, Demiryürek H, Yağmur Ö. “Percutaneous placement of self-expandable uncovered metallic stents in malignant biliary obstruction: complications, follow-up and reintervention in 154 patients”. acta. radiol. 44, 139-146, (2003).

İnal M , Akgül E, Aksungur E, Seydaoğlu G. Percutaneous placement of biliary metallic stents in patients with malignant hilar obstruction: unilobar versus bilobar drainage. J. Vasc. Interv. radiol. 14, 1409-1416, (2003).

Inal M, Oğuz M, Aksungur E, Soyupak S, Börüban S, Akgül E. “Biliary enteric fistulas: Report of five cases and review of the literature”. EUR. radiol. 9, 1145-1151, (1999).

İnal M , Aksungur EH, Akgül E, Demirbaş Ö, Oğuz M, Erkoçak E. “Biliary tuberculosis mimicking cholangiocarcinoma: Treatment with metallic endoprothesis”. am. J. Gastroenterol. 95, 1069-71, (2000).

İnal M , Soyupak S, Akgül E, Ezici H. “Percutaneous transhepatic endobiliary drainage of hepatic hydatid cyst with rupture into the biliary system: unusual route for drainage”. cardiovasc. Intervent. radiol. 25, 437-439, (2002).

İnal M , Doran F, Soyupak S, Uğuz A, Akgül E, Okur N. “Percutaneous biliary drainage: an alternative treatment for biliary fascioliasis”. Abdom. imaging. 27, 552-556, (2002).

(b) My talk about percutaneous biliary interventions:

1. İnal M . “Emergency Percutaneous Biliary Interventions”. 25. National Radiology Congress, Antalya, 2004.

2. İnal M. “Approach to pancreatic tumors”. 7. National Hepato-Pancreato-Biliary Surgery Congress, Adana, 5-8 May, 2005.

3. İnal M. “Cholangitis, cholangitis abscesses and biliary sepsis: Diagnostic and Interventional Radiological Approach”. 26. National Radiology Congress, Antalya, 2005.

4. İnal M. Current Approaches and Complications in Gastrointestinal Surgery. Scientific Communication Meetings. III.Meeting: “Non-invasive radiological approaches to the liver and biliary tract”. 25 March 2006, Gaziantep.

5. İnal M. “Interventional Radiology in Malignant Biliary Obstruction”. Turkish Society of Cardiovascular and Interventional Radiology-Interventional Radiology Symposium, Hacettepe/Ankara, 30 March-1 April 2007.

6. İnal M. “Acute Pancreatitis: Radiological Interventions”. Current Approaches and Complications Meeting in Gastrointestinal Surgery, Adana, 16 February 2008.

7. İnal M.“Interventional Radiology in Malignant Biliary Obstruction” IV. Annual Meeting of Interventional Radiology, Ankara, 9-11 April 2009.

8. İnal M. “Hepatobiliary Radiological Interventions” 2nd Regional General Surgery-Internal Medicine Dialogue Symposium. Antakya, 30 April 2011.

9. Inal M. “Symposium on Problematic Diseases in General Surgery”. Management of Biliary Tract Injuries. Adana, 6-7 May 2011.

10. Inal M. “The Gallbladder and the Bile Tracts”. Hepatopancreatobiliary MRI Course. Turkish Magnetic Resonance Society. Malatya, 07 April 2012.

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