Percutaneous Transhepatic - PowerPoint Presentation

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Percutaneous TranshepaticCholangiography andBiliary Intervention

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IndicationsTreatment of malignant obstructionAdjunct to surgery

Treatment of CBD calculi

Treatment of benign strictures

Diagnostic?

Failed ERCP

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Patient selectionWHO performance statusImaging

Clinician/MDT discussion

Coagulation status

Ascites

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WHO performance status0 – 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

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ImagingUltrasound. 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

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Clinician/MDT discussion

Malignant or benign disease

Gastroenterologists

Surgeons

Radiologists

Other Healthcare Workers

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

Palliative. ERCP or PTC and metallic Stent

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Benign DiseaseERCP treatment of choicePTC and internal/external drain or plastic stent

. May enable successful ERCP later

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Coagulation statusINR < 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

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ConsentWHO performance statusCheck coagulation

Explain procedure at least 1 day before

Risks. Bleeding, bile leak, infection, pneumothorax and failure

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AnaestheticAnaesthetistGA

Discuss need for airway protection

Use LA

When applying for consultant post ask what access you may have to anaesthetics

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AntibioticsAt start of procedureGentamicin 240 mg IV

Metronidazole 500 mg IV

Discuss with Microbiology

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EquipmentUse 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

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Approach/Technique 1Ascites 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

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Approach/Technique 2Pre-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

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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)

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Approach/Technique 4Unable to cross stricture, establish external drainage (8.5F internal/external drain). Further attempt after decompression usually successful.

Care with drainage bag essential

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Internal external drainage, try not to use bag and bung catheter.

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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

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BSIR recommendations1. 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

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Case 186 yr female presented with sepsis and subsequent jaundice

Arteriopath

but otherwise reasonably fit

CT

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Case 1Abscess right lobe liver drained Antibiotics

MDT discussion, for palliation

ERCP, failed to stent due to large duodenal diverticulum

PTC

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Case 269 yr male with obstructive jaundiceCT, operable mass in head of pancreas

MDT discussion

Surgical candidate

ERCP to place plastic stent failed

PTC

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Case 375 yr female with obstructive jaundiceCT, large central liver mass, likely cholangiocarcinoma. Further deposit in segment II

MDT discussion, not operable, palliative

PTC and stent left lobe

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Case 471 yr maleMetastatic 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

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Case 559 yr female with inoperable cholangiocarcinoma

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

Recurrent jaundice

?percutaneous options

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Take Home PointsCareful patient selection after MDT discussion

“Appropriate” Anaesthesia

Try not to use external

drainage bags