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Biliary tract interventions remain indispensable procedures for treatment of a wide arena of biliary tract pathologies. The increased use of endoscopic retrograde cholangiopancreatography (ERCP) for biliary tract evaluation and intervention has resulted in fewer patients requiring percutaneous transhepatic biliary interventions. However, there rema...
Citations
... A major challenge of either endoscopic or percutaneous approach is the difficulty in traversing tight perihilar obstructions caused by perihilar MBOs. This can be overcome with a rendezvous approach (combined ERCP/ percutaneous approach) or may require initial placement of an external drain and reattempt at a later date (usually after 1 week or later) [6,7]. Only recently have the expertise and technical support for regular performance of both endoscopic and percutaneous biliary interventions become available in Nigeria [8][9][10]. ...
Background
A major challenge of either endoscopic or percutaneous approach to placing palliative biliary stents is the difficulty in traversing tight perihilar malignant obstructions. This can be overcome with a rendezvous approach (combined endoscopic retrograde cholangiopancreatography (ERCP)/percutaneous approach) or may require initial placement of an external drain and reattempting later. Interventional radiology for biliary obstruction is still in infant days in our locality. Herein, we describe two cases of perihilar malignant biliary obstruction (MBO) managed at a private facility in Lagos, Nigeria, in which we had to come up with a creative approach to crossing these tight junctions in the absence of ERCP facilities. This was done by securing percutaneous retrograde access into the common bile duct and combining it with the initially unsuccessful anterograde approach. In both cases, this combined percutaneous anterograde/retrograde approach resulted in successful traversal of the malignant obstruction and placement of internal biliary stents.
Case presentation
We present the case of two elderly patients with tight malignant biliary obstruction (MBO), one from a suspected cholangiocarcinoma and the other from hepatic metastatic colorectal carcinoma. Both patients had successful traversal of the obstruction via a combined percutaneous anterograde/retrograde approach and biliary stenting.
Conclusions
Our case reports demonstrate an unusual approach that should assist interventional radiologists in resource-limited setting who seek for a viable option to those presently available for traversing perihilar MBOs in the percutaneous placement of internal stents.
... Biloma is a rare condition with an incidence of 0.3% to 2.0% and is usually presented in patients aged 60 to 70 years old [3,4]. Biloma formation is most commonly a result of choledocholithiasis, iatrogenic injury and abdominal trauma, causing disruption to the biliary tree and furthermore bile leakage into the peritoneal cavity [4,5]. Although it is not common, bile leakage could also occur spontaneously, known as spontaneous bile leak (SBL), which is usually a diagnosis of exclusion [6]. ...
A biloma is a loculated, extrahepatic, intra-abdominal bile collection. It is an unusual condition with an incidence of 0.3–2% and is usually a result of choledocholithiasis, iatrogenic injury or abdominal trauma causing disruption to the biliary tree. Rarely, it will occur spontaneously, resulting in spontaneous bile leak. We herein present a rare case of biloma as a complication of endoscopic retrograde cholangiopancreatography (ERCP). A 54-year-old patient experienced right upper quadrant discomfort, following ERCP, endoscopic biliary sphincterotomy and stenting for choledocholithiasis. Initial abdominal ultrasound and computed tomography revealed an intrahepatic collection. Percutaneous aspiration under ultrasound guidance of yellow-green fluid confirmed the diagnosis, indicated infection and contributed to effective management. Most likely, a distal branch of the biliary tree was injured during the insertion of the guidewire through the common bile duct. Magnetic resonance image/magnetic resonance cholangiopancreatography contributed in the diagnosis of two seperate bilomas. Even though post ERCP biloma is an unusual complication, differential diagnosis of patients with right upper quadrant discomfort following an iatrogenic or traumatic event should always include biliary tree disruption. A combination of radiological imaging for diagnosis and minimal invasive technique to manage a biloma can prove to be successful.
... Even though most causes of obstructive jaundice are benign in nature, the common indications for biliary drainage procedure are due to malignant lesions producing biliary obstruction. 1 In malignant causes, periampullary carcinoma is the most common, followed by hilar cholangiocarcinoma. 1,2 In addition to jaundice, patients may present with pruritus which occurs in 50 to 80% of malignant cases. 3 Abdominal pain occurs in majority of benign cases, while in malignancy it is seen in 50 to 60% and occurs late. ...
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.
... It can present with acute symptoms or gradually progressive indolent course depending upon the underlying cause. 2 Percutaneous transhepatic biliary drainage (PTBD) is a minimally invasive procedure for drainage of the biliary system. 3 PTBD is preferred as the primary procedure in patients who have had prior bilio-enteric anastomosis, or those who are unsuitable for endoscopic retrograde cholangiopancreatography (ERCP) due to other reasons. Imaging plays an essential role in the diagnosis of underlying etiology and provides a road map for the procedures. ...
... Percutaneous transhepatic biliary drainage (PTBD) may be performed for both benign and malignant causes. 3 It can be used as a palliative procedure in nonoperable patients, a bridging procedure for further biliary stenting, or as an emergency procedure for clinically unstable patients presenting with acute severe cholangitis. ►Table 2 highlights the indications for PTBD. ...
Percutaneous transhepatic biliary drainage (PTBD) is one of the commonly performed biliary interventions. In patients with obstructive jaundice, PTBD may be a lifesaving emergency procedure or may serve as an alternative intervention in patients who fail to undergo endoscopic drainage or those who are too sick to be considered for endoscopic drainage. The key factor in technical and clinical success of PTBD is a thorough preprocedure imaging evaluation. In this review, we highlight the imaging aspects that should be evaluated and reported by a radiologist when evaluating a patient planned for biliary drainage.
Acute cholangitis presents with a wide severity spectrum and can rapidly deteriorate from local infection to multiorgan failure and fatal sepsis. The pathophysiology, diagnosis, and general management principles will be discussed in this review article. The focus of this article will be on the role of biliary drainage performed by interventional radiology to manage acute cholangitis. There are specific scenarios where percutaneous drainage should be preferred over endoscopic drainage. Percutaneous transhepatic and transjejunal biliary drainage are both options available to interventional radiology. Additionally, interventional radiology is now able to manage these patients beyond providing acute biliary drainage including cholangioplasty, stenting, and percutaneous cholangioscopy/biopsy.
