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Background: The aim of this study was to explore the efficacy and safety of endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTCD) in patients ...

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

To evaluate the safety and efficacy of percutaneous stone removal using a compliant balloon after papillary balloon dilatation.Between March 2014 and May 2020, 123 patients with choledocholithiasis, in whom endoscopy was unsuccessful, were enrolled in this study. The ampulla of Vater was dilated using a noncompliant balloon, and stone removal was attemptedBiliary stones were completely removed in 118 of 123 patients. Major complications occurred in five patients. One patient experienced duodenal bleeding, which was successfully treated by endoscopy. Hemobilia occurred in three patients, which required transfusion, and one patient experienced four days of abdominal pain. Minor complications, including self-limiting pain, effusion, minimal hemobilia, elevated amylase and fever, occurred in 21 patients. Stone size was the only significant risk factor associated with the rate of complications (Odds ratio: 1.14, 95% confidence interval = 1.04, 1.26). Bilirubin and white blood cell levels significantly decreased after the procedure.Percutaneous stone removal using a compliant balloon after papillary balloon dilatation is a safe and effective method in patients in whom endoscopic or surgical treatment is not feasible.

AIMS: To evaluate the echogenicity of a commercially available needle, modified on the tip, by comparing two groups of patients undergoing to percutaneous biliary drainage. METHODS: In this retrospective analysis 16 percutaneous transhepatic biliary drainage (PTBD) procedures performed on 16 oncologic patients were evaluated. Patients were randomly divided into two groups of eight subjects each; in the first group, a standard needle was adopted (group A); in the second group, the needle was manually modified to create a rough surface (group B), by scrubbing the tip with an 11 scalpel blade for 150 s all around its surface. To objectively quantify US needle tip visibility, the contrast-to-noise ratio (CNR) was calculated analyzing B-mode images by positioning region of interests in correspondence of needle tip and liver parenchyma. RESULTS: Needle tip echogenicity was significantly higher in group B where the needle tip was modified compared to control group A (p value = 0.014). CNR, considered to objectively evaluate differences among needle tip echogenicity, was significantly higher in group B with respect to control group A (p value = 0.018). CONCLUSIONS: The proposed method, scrubbing a 22 gauge commercially available needle tip with a scalpel blade, represents an effective technique to improve needle visibility during US-guided punctures of the liver.

Intraductal cooling via a percutaneous transhepatic biliary drainage tube holds great promise in facilitating thermal ablation of liver tumors adjacent to the central bile ducts. However, the difficulties and complications associated with puncturing nondilated bile ducts are greater than those associated with puncturing dilated bile ducts. As reported here, percutaneous transcholecystic contrast-enhanced ultrasound was performed in 7 patients to visualize the nondilated bile ducts and guide percutaneous transhepatic biliary drainage, thus facilitating the intraductal cooling-assisted thermal ablation process. The procedures were technically successful in all 7 patients, and no major complications were recorded during the follow-up period.

Background Endoscopic ultrasound (EUS)-guided ductal access and drainage (EUS-DAD) of biliary/pancreatic ducts after failed endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than percutaneous transhepatic biliary drainage (PTBD). The actual need for EUS-DAD remains unknown. We aimed to determine how often EUS-DAD is needed to overcome ERCP failure. Methods Consecutive duct access procedures (n = 2205; 95 % biliary) performed between June 2013 and November 2015 at a tertiary-care center were reviewed. ERCP was used first line, EUS-DAD as salvage after ERCP, and PTBD when both had failed. Procedures were defined as “index” in patients without prior endoscopic duct access and “combined” when EUS-DAD followed successful ERCP. The main outcomes were the EUS-DAD and PTBD rates. Results EUS-DAD was performed in 7.7 % (170/2205) of overall procedures: 9.1 % (116/1274) index and 5.8 % (54/931) follow-up. Most index EUS-DADs were performed following (46 %) or anticipating (39 %) ERCP failure, whereas 15 % followed successful ERCP (combined procedures). Among index procedures, the EUS-DAD rate was higher in surgically altered anatomy (58.2 % [39 /67)] vs. 6.4 % [77/1207]); PTBD was required in 0.2 % (3/1274). Among follow-up procedures, ERCP represented 85.7 %, cholangiopancreatography through mature transmural fistulas 8.5 %, and EUS-DAD 5.8 %; no patient required PTBD. The secondary PTBD rate was 0.1 % (3/2205). Six primary PTBDs were performed (overall PTBD rate 0.4 % [9/2205]). Conclusions EUS-DAD was required in 7.7 % of ERCPs for benign and malignant biliary/pancreatic duct indications. Salvage PTBD was required in 0.1 %. This high EUS-DAD rate reflects disease complexity, a wide definition of ERCP failure, and restrictive PTBD use, not poor ERCP skills. EUS-DAD effectively overcomes the limitations of ERCP eliminating the need for primary and salvage PTBD in most cases.

To compare the technical difficulty, safety, radiation exposure and success rates between right-sided and left-sided percutaneous transhepatic biliary drainage (RPTBD and LPTBD) in patients with malignant biliary obstruction (MBO). Fifty patients (28 males, 22 females; mean age 51.78 years) with MBO were randomized to undergo either RPTBD or LPTBD during the study period between June 2016 and May 2018. The procedure time, fluoroscopy time, radiation doses to the operators and patients, technical success, clinical success, complications and effect on quality of life were evaluated and compared between the two groups. Twenty-five patients were included in each group. The technical success was 100% in both groups. There was no significant difference between RPTBD and LPTBD groups in terms of major complications [4% and 12%, respectively; p = 0.297] and minor complications [40% and 32%, respectively; p = 0.597]. Further, the average procedure time (37.80 ± 13.07 min vs 41.04 ± 14.94 min), fluoroscopy time (5.88 ± 4.2 min vs 5.97 ± 3.8 min), radiation doses to the operator (136.84 ± 106.67 μSv vs 130.40 ± 106.46 μSv) and to the patient (8.23 ± 5.80 Gycm2 vs 11.74 ± 11.28 Gycm2) were not significantly different between the groups. Clinical success was achieved in 21 patients (84%) of RPTBD group and 17 patients (68%) of LPTBD group with no significant difference (p = 0.416) between them. There was no significant difference between RPTBD and LPTBD with reference to the technique, safety, radiation dose, success rates and impact on quality of life suggesting no laterality advantage for biliary drainage in cases of MBO.

Rationale: Cerebral air embolism from portal venous gas rarely occurs due to invasive procedures (e.g., endoscopic procedures, liver biopsy, or percutaneous transhepatic biliary drainage) that disrupt the gastrointestinal or hepatobiliary structures. Here, we report a rare case of fatal cerebral air embolism following a series of percutaneous transhepatic biliary drainage tube insertions. Patient Concerns: A 50-year-old woman with a history of cholecystectomy, liver wedge resection, and hepaticojejunostomy for gallbladder cancer presented with altered mental status 1 week after percutaneous transhepatic biliary drainage tube placement. Diagnoses: Extensive cerebral air embolism and acute cerebral infarction. Interventions: Brain computed tomography and magnetic resonance imaging, hyperbaric oxygen therapy, medical therapy. Outcomes: Despite the use of hyperbaric oxygen therapy and medical treatment including vasopressors, the patient eventually died due to massive systemic air embolism. Lessons: To date, there have been no reports of cerebral air embolism due to percutaneous transhepatic biliary drainage with pronounced radiologic images. We reviewed previously reported fatal cases associated with endoscopic hepatobiliary procedures and assessed the possible mechanisms and potential causes of air embolism.

Endoscopic retrograde cholangiopancreatography is not always successful even with needle knife precut sphincterotomy (NKPS). How to manage these patients with initial NKPS failure has not been well studied. We report the outcomes of patients who received endoscopic and non-endoscopic rescue treatment after the initial NKPS failure. During the 15 years from 2004 to 2018, 87 patients with initial NKPS failure received interval endoscopic treatment (IET group, n = 43), percutaneous transhepatic biliary drainage (PTBD group, n = 25), or bile duct surgery (BDS group, n = 19) were retrospectively studied. Compared with the PTBD group, the prevalence of choledocholithiasis was higher (69.8% vs. 16.0%, p

Despite advances in endoscopic drainage procedures, percutaneous transhepatic biliary drainage (PTBD) remains an essential interventional radiology (IR) procedure. Several factors may adversely affect the success of PTBD. We report the experience of our IR unit with PTBD in patients considered at higher risk for adverse events. Consecutive PTBDs performed between November 2017 and April 2019 were retrospectively reviewed. The patients at increased risk for adverse events from PTBD, defined by one or more of the following factors: non-dilated system, moderate amount of perihepatic fluid, coagulopathy, altered sensorium, and PTBD performed at bedside, were identified. Technical success, complications, and outcome at 3 months were recorded. During the study period, PTBDs were performed in 90 patients. PTBDs in 57 (63.3%) patients (mean age 47.6 years, 35 females) were identified as predisposing to higher risk for adverse events. Left and right PTBD were performed in 37 (64.9%) and 15 (26.3%) patients, respectively. Bilateral PTBDs were performed in three (5.2%) patients. In two (3.5%) cases, biliary access was obtained via percutaneous cholecystostomy. Overall technical success of 91.2% (n = 52) was achieved. Carcinoma gallbladder was the most common underlying cause. Non-dilated ductal system was the most common condition deemed to predispose to higher risk for adverse events (n = 32, 56.1%), followed by perihepatic fluid (n = 9, 15.8%), and deranged coagulation parameters (n = 9, 15.8%). PTBD was performed at bedside in intensive care unit in 5 (8.8%) patients. Two (3.5%) patients had altered sensorium. Major complications in the form of biliary peritonitis were observed in three (5.2%) patients. No procedure-related mortality was observed. PTBD can be effectively and safely performed even in situations deemed to predispose patients to increased risk for adverse events. Thus, the mere presence of these conditions should not cause a denial of PTBD.

Background Only 3 case reports have addressed pleural dissemination in association with percutaneous transhepatic biliary drainage. The aim of this study was to investigate recurrence after resection of cholangiocarcinoma after percutaneous transhepatic biliary drainage and to clarify the incidence of and the factors responsible for pleural dissemination. Methods Between 2001 and 2015, we reviewed retrospectively all consecutive patients who underwent resection for perihilar or distal cholangiocarcinoma after percutaneous transhepatic biliary drainage for recurrence, including pleural dissemination. Results During the study period, all consecutive patients underwent resection of cholangiocarcinoma after management with percutaneous transhepatic biliary drainage. Of these, 100 patients (32.1%) underwent left-sided percutaneous transhepatic biliary drainage alone, and 212 (67.9%) underwent right-sided percutaneous transhepatic biliary drainage with or without left-sided percutaneous transhepatic biliary drainage. Pleural dissemination, which developed exclusively on the right side of the thoracic cavity after resection, was found in 12 patients (3.8%); these patients underwent right-sided percutaneous transhepatic biliary drainage; computed tomography demonstrated that the percutaneous transhepatic biliary drainage catheter passed through the thoracic cavity in all 12 patients. The diagnosis of pleural dissemination was made at a median of 381 days (range, 44 to 2,944 days) after operation. Survival was poor, with a median survival time of 516 days. Statistically, right-sided percutaneous transhepatic biliary drainage was identified as a risk factor for pleural dissemination. Conclusion Pleural dissemination after right-sided percutaneous transhepatic biliary drainage is likely a procedure-related iatrogenic complication because of the “special route” by which the percutaneous transhepatic biliary drainage catheter must be passed through the right thoracic cavity.

BACKGROUND Biliary strictures (BS) are frequent after pediatric liver transplantation (LTx) and in spite of ongoing progress, they remain a significant cause of morbidity. In children, the majority of reconstruction is hepatico-jejunal anastomosis (HJA). The aim of this study was to analyze our experience in percutaneous transhepatic treatment of BS. MATERIAL AND METHODS Between 1998 and 2014, 589 (269 living donor) pediatric LTx were performed in our institution. We retrospectively reviewed clinical data of patients with HJA who developed BS and who underwent percutaneous transhepatic biliary drainage (PTBD). RESULTS Out of 400 patients with HJA, 35 patients developed BS. There were 27 cases (77%) of anastomotic BS (ABS) and 8 cases (23%) of multilevel BS (MBS). Ninety-two PTBD sessions (2.5 per patient) were performed, with successful outcomes in 20 cases (57%). Fifteen patients, after failed PTBD, underwent surgery which was successful in 11 cases. Overall good outcomes were achieved in 31 cases (88.5%). The most common complication of PTBD was cholangitis which occurred in 5.4% of the cases. We did not find any risk factors for PTBD failure, except for treatment occurring before 2007. CONCLUSIONS Percutaneous treatment is effective and safe in BS and is recommended as a first-line approach. The majority of patients in our study required multiple interventions, however, the overall risk of complications was low. Surgery is essential in selected cases and always should be considered if PTBD fails.

Background Complementary to percutaneous intra-abdominal drainage, percutaneous transhepatic biliary drainage (PTBD) might ameliorate healing of pancreatic fistula and biliary leakage after pancreatoduodenectomy by diversion of bile from the site of leakage. This study evaluated technical and clinical outcomes of PTBD for this indication. Methods All patients undergoing PTBD for leakage after pancreatoduodenectomy were retrospectively evaluated in two tertiary pancreatic centers (2014–2019). Technical success was defined as external biliary drainage. Clinical success was defined as discharge with a resolved leak, without additional surgical interventions for anastomotic leakage other than percutaneous intra-abdominal drainage. Results Following 822 pancreatoduodenectomies, 65 patients (8%) underwent PTBD. Indications were leakage of the pancreaticojejunostomy (n = 25; 38%), hepaticojejunostomy (n = 15; 23%) and of both (n = 25; 38%). PTBD was technically successful in 64 patients (98%) with drain revision in 40 patients (63%). Clinical success occurred in 60 patients (94%). Leakage resolved after median 33 days (IQR 21–60). PTBD related complications occurred in 23 patients (35%), including cholangitis (n = 14; 21%), hemobilia (n = 7; 11%) and PTBD related bleeding requiring re-intervention (n = 4; 6%). In hospital mortality was 3% (n = 2). Conclusion Although drain revisions and complications are common, PTBD is highly feasible and appears to be effective in the treatment of biliopancreatic leakage after pancreatoduodenectomy.

European radiology 31(5), 3035-3041 (2021). doi:10.1007/s00330-020-07368-6, Published by Springer, Berlin

Background/aim Malignant obstructive jaundice (MOJ) is a common condition caused by several primary and secondary cancers. We performed a systematic review and meta-analysis to investigate technical success rate and safety of percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD) in MOJ. Materials and methods Relevant trials were identified by searching electronic databases and conference meetings. We included thirteen retrospective studies and four randomized controlled trials, with PTBD performed in 2353 patients and EBD in 8178 patients. Outcomes of interest included: technical success rate, overall complications, 30-day mortality rate and risk of bleeding, pancreatitis, cholangitis and tube dislocation. Results The differences in technical success rate, total complications, 30-day mortality rate and tube dislocation were not statistically significant between the two groups. Patients receiving PTBD showed a lower risk of pancreatitis (OR=0.14, 95%CI=0.06-0.31) and cholangitis (OR=0.52, 95%CI=0.30-0.90) when compared to EBD while PTBD was associated with higher risk of bleeding (OR=1.78; 95%CI=1.32-2.39). Conclusion Our meta-analysis indicates the presence of some advantages and limits for both PTBD and EBD. We highlight the paucity of quality-of-life data, a vital element which should be carefully pondered in future studies and in choosing the optimal technique in patients with MOJ.

Objectives: To compare the clinical outcomes of endoscopic biliary drainage (EBD) with those of percutaneous transhepatic biliary drainage (PTBD) in patients with resectable hilar cholangiocarcinoma (HCCA) and evaluate the effect of EBD and PTBD on tumor prognosis. Materials and methods: PubMed, EMBASE, and Cochrane Library databases were searched for articles about the comparison between PTBD and EBD. Data were analyzed by Revman 5.3. Results: PTBD showed a lower risk of drainage-related complications than EBD (OR, 2.73; 95%CI, 1.52–4.91; P .05). Several literatures have reported the tumor implantation metastasis after PTBD. Since no well-designed prospective randomized controlled studies have explored in this depth, this article is unable to draw conclusions on this aspect. Conclusion: PTBD is a reasonable choice for PBD, and EBD should only be used as preoperative drainage for HCCA by more experienced physicians. There is a greater need to design prospective randomized controlled studies to obtain high-level evidence-based medicinal proof. It is worth noting that, whether EBD or PTBD, accurate selective biliary drainage should be the trend.

We report two cases of interventional radiologists who had been exposed to radiation while performing fluoroscopically-guided interventional procedures (FGIPs), mainly transcatheter arterial chemoembolization, percutaneous catheter drainage, and percutaneous transhepatic biliary drainage procedures, for over 10 years. They had a unique multi-aberrant cell type with not only high numbers of dicentrics and/or centric rings but also excess acentric double minutes, similar to a rogue cell. As revealed in a self-administered questionnaire, they wore personal dosimeters and protective equipment at all times and used shielding devices during interventional fluoroscopy procedures. However, the exposed dose levels derived from cytogenetic dosimetry were much higher than the doses recorded on their personal dosimeters. A large number of unstable and stable chromosomal aberrations that were found in the peripheral blood lymphocytes of these interventional radiologists might be due to repeated and long-term exposure to ionizing radiation while performing FGIPs. Further investigations of chromosomal aberrations in interventional radiologists may improve the understanding of the long-term effects of radiation exposure on medical personnel.

Preoperative biliary drainage may increase the morbidity and mortality of pancreaticoduodenectomy. Studies on percutaneous transhepatic biliary drainage (PTBD) before laparoscopic pancreaticoduodenectomy (LPD), however, are scarce. The aim of this study was to examine the impact of PTBD on clinical outcomes of patients with malignant obstructive jaundice undergoing LPD. Clinical data of 172 patients who had malignant obstructive jaundice and underwent LPD from 2014 to 2017 in our hospital were retrospectively analyzed. Demographics, catheter-related complications, postoperative complications, and oncological outcomes were collected and analyzed. Propensity score matching was performed to minimize selection bias associated with the comparison of data between patients who underwent PTBD and then LPD (PTBD group), and those given LPD alone (LPD group). The results showed that, in the PTBD group relative to the LPD group, the operating time was significantly shortened (250.28±69.95 vs. 278.58±86.51 min, P=0.0196), the intraoperative blood loss was markedly reduced (271.96±403.47 vs. 429.72±482.47 mL, P=0.022), and overall rates of complications (16.33% vs. 36.49%, P=0.0025) including postoperative haemorrhage (2.04% vs. 12.16%, P=0.0072) and delayed gastric emptying (4.08% vs. 13.51%, P=0.0251) were greatly decreased. The propensity score-matched analysis, with 48 patients enrolled in each group, revealed no statistically significant differences in operating duration (262.71±68.64 vs. 280.25±83.52 min, P=0.264), intraoperative blood loss (290.21±407.71 vs. 373.75±422.33 mL, P=0.327) and delayed gastric emptying (4.17% vs. 12.50%, P=0.1396). PTBD group had lower incidences in overall complications (22.92% vs. 39.58%, P=0.0481) and postoperative haemorrhage (2.08% vs. 12.50%, P=0.0497) than LPD group. In conclusion, patients with malignant obstructive jaundice may benefit from PTBD procedure before LPD in terms of perioperative outcomes.

Conversion factors used to estimate effective (E) and organ doses (HT) from air Kerma area product (KAP) are required to estimate population doses in percutaneous transhepatic biliary drainage (PTBD) and trans arterial chemoembolization (TACE) interventional procedures. In this study, E and HT for ten critical organs/tissues, were derived in 64 PTBD and 48 TACE procedures and in 14,540 irradiation events from dosimetric, technical and geometrical information included in the radiation dose structured report using the PCXMC Monte Carlo model, and the ICRP 103 organ weighting factors. Conversion factors of: 0.13; 0.19; 0.26 and 0.32 mSv Gy−1 cm−2 were established for irradiation events characterized by a Cu filtration of 0.0; 0.1; 0.4 and 0.9 mm, respectively. While a single coefficient of conversion is not able to provide estimates of E with enough accuracy, a high agreement is obtained between E estimated through Monte Carlo methods and E estimated through E/KAP conversion factors accounting separately for the different modes of fluoroscopy and the fluorography component of the procedures. An algorithm for the estimation of effective and organ doses from KAP has been established in biliary procedures which considers the Cu filtration in the X-ray irradiation events. A similar algorithm could be easily extended to other interventional procedures and incorporated in radiation dose monitoring systems to provide dosimetric estimates automatically with enough accuracy to assess population doses.

Background: The various techniques for relief of malignant biliary obstruction include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage (PTBD), and endoscopic ultrasound guided biliary drainage (EUS-BD). We conducted a systematic review and network meta-analysis (NMA) comparing all three modalities with respect to efficacy, adverse events, and re-intervention rate. Methods: We searched multiple databases from inception to October 2019 to identify comparative studies of malignant biliary obstruction patients treated with EUS-BD, ERCP or PTBD. Outcomes of interest were technical success, clinical success, adverse events and need for re-intervention. Pooled odds ratios (OR) were calculated and analyzed using the random effects model. To incorporate indirect comparisons, we conducted NMA using a multivariate, consistency model with random-effects meta-regression. We followed the GRADE approach to rate the certainty of evidence. Findings: We included 17 studies; of which 8 were randomized (3 EUS vs ERCP; 1 EUS vs PTBD; 13 ERCP vs PTBD) with 1566 patients (220: EUS vs ERCP; 33: EUS vs PTBD; 1313: ERCP vs PTBD). NMA did not show statistically significant differences to favor one intervention with certainty over the other across multiple outcomes. The analysis suggested that PTBD may have a higher clinical and technical success rate than ERCP and that EUS may have a lower re-intervention rate than ERCP. Interpretation: The available evidence cannot favor one of the 3 interventions with certainty across multiple outcomes. Shared-decision making is recommended to choose the approach most consistent with patient’s values, goals of treatment and comorbidities and consider the availability of procedural expertise. Funding: None. Conflict of Interest: None.

Background: Percutaneous transhepatic biliary drainage (PTBD) plays a significant role especially in the palliation of an endoscopically inaccessible biliary system. Since a standard technique of PTBD is not defined, we compared a fluoroscopically guided technique (F-PTBD) with an ultrasound (US-PTBD) guided approach. Patients and Methods: Procedure characteristics, success-rates and complication-rates of the different PTBD techniques were compared in patients who underwent PTBD between October 1, 2006, and ­December 31, 2014. Results: In 195 patients, 251 PTBDs (207 F-PTBDs, 44 US-PTBDs) were performed. F-PTBDs were mostly inserted from the right and US-PTBDs from the left. Patient age, gender and physical status were comparable in both techniques. There was no difference regarding overall procedure success (90%/86.4%), overall interventional complication rates (10.6%/9.1%), fluoroscopy times, intervention times or sedatives dosages. However, major complications were only encountered in F-PTBDs. There was a higher success rate for F-PTBD vs. US-PTBD from the right side (91.9 vs. 75%; p = 0.033) and a trend towards a higher success rate for US guidance from the left side (82.9 vs. 95.8%; p = 0.223). Conclusions: For drainage of the right biliary system F-PTBD seems superior over the US-PTBD technique used in this study. However, major complications can occur more frequently in F-PTBD.

To assess the effectiveness of percutaneous radiological treatment for complex biliary leaks compared to simple biliary leaks. We retrospectively analyzed 101 percutaneous treatments for bile leak performed from January 1994 to January 2012. Sixty (59%) bile leaks were classified as simple and 41 (41%) as complex based on a morphological classification that considered eight types of biliary wound on cholangiography images. The main treatment was percutaneous transhepatic biliary drainage (PTBD), and additional procedures were performed when required. The technical success of PTBD, leak healing, and recurrence, as well as complication rates were compared between the simple and complex leak groups. Technical success of PTBP was achieved in 94/101 (93%) patients: 59/60 (98%) for simple leaks and 35/41 (85%) for complex leaks (p = 0.017). When PTBD internalization was achieved, leak healing was obtained in 80/94 (85%) patients: 52/59 (88%) for simple leaks and 28/35 (80%) for complex leaks (p = 0.37), with additional percutaneous procedures required in five patients with simple leaks and 13 patients with complex leaks (p = 0.001). There was no recurrence in 75/80 (94%) patients: 50/52 (96%) for simple leaks and 25/28 (89%) for complex leaks (p = 0.34). Major complications occurred in 28/101 (28%) patients: 16/59 (27%) for simple leaks and 12/41 (29%) for complex leaks (p = 0.82). Once PTBD internalization is achieved, complex leaks heal as well as simple leaks.

The goal of the study is to compare the efficacy and safety of bile duct drains guided by endoscopic ultrasound-guided biliary drainage (EGBD) versus percutaneous transhepatic biliary drainage (PTBD).Retrospective comparative study. Patients with obstruction of the bile duct who underwent the EGBD or PTBD procedure and had at least 1 previous endoscopic retrograde cholangiopancreatography that failed or was inaccessible to the second duodenal portion were included.A total of 90 patients were initially evaluated and 28 were excluded. There were 39 (62.9%) women, with a median age of 55.6 years (range, 22 to 88 y). The etiology of biliary obstruction was malignancy in 35 (56.4%) patients. Differences between EGBD versus PTBD groups were in technical success (90% vs. 78%; P=0.3), clinical success (96% vs. 63%; P=0.04), complications (6.6% vs. 28%; P=0.04), length of stay [6.5 d (range, 0 to 11 d) vs. 12.5 d (range, 6.2 to 25 d)] (P=0.009), and costs 1440.15±240.94 versus 2165.87±241.10 USD (P=0.03).EGBD is associated with a higher clinical success rate and safety, shorter hospital stays, and lower cost compared with PTBD.

Purpose The purpose of this study was to retrospectively assess the potential of percutaneous transhepatic biliary drainage (PTBD) in patients with nondilated bile ducts (NDBD) using a transgallbladder opacification of the bile ducts. Patients and methods Eight patients with NDBD (7 men, 1 women; median age, 65 years; Q1–Q3, 35–69 years; range, 22–77 years) who underwent PTBD after opacification of the bile ducts through the gallbladder were evaluated. Opacification of NDBD was performed using a retrograde injection of contrast material through the gallbladder. The opacified peripheral NDBD was punctured percutaneously and a drainage catheter was introduced under fluoroscopy guidance. The success and safety of the procedure were assessed. Results PTBD could be achieved in 6/8 patients (75%) and no significant complications were observed. The biliary tree opacification was attempted but could not be achieved due to biliary sludge that obstructed the cystic duct in 2/8 patients (25%). Two minor complications in two different patients were observed consisting of transient hemobilia and chills. Conclusion Opacification of the bile ducts using a transgallbladder approach appears to be a safe and successful procedure for PTBD in patients with NDBD.

Background: The symptoms of patients with malignant biliary obstruction (MBO) could be effectively alleviated with percutaneous transhepatic biliary drainage (PTBD). Postoperative infections were considered as challenging issues for clinicians. In this study, the risk factors of biliary infection in patients after PTBD were analyzed. Methods: From July 2003 to September 2010, 694 patients with MBO received PTBD treatment. Bile specimens were also collected during PTBD. All relevant information and results were collected, including gender, age, obstruction time, types of primary tumor, sites of obstruction, drainage style, tumor stage, hemoglobin, phenotype of peripheral blood monocyte (Treg), total bilirubin, direct bilirubin, albumin, Child–Pugh score, and results of bile bacterial culture. Results: For the 694 patients involved in this study, 485 were male and 209 were female, with a mean age of 62 years (ranged 38–78 years). For the bile culture, 57.1% patients (396/649) were negative and 42.9% patients showed positive (298/694), and then 342 strains of microorganism were identified. The risk factors of biliary system infection after PTBD included: age (χ2 = 4.621, P = 0.032), site of obstruction (χ2 = 17.450, P < 0.001), drainage style (χ2 = 14.452, P < 0.001), tumor stage (χ2 = 4.741, P = 0.029), hemoglobin (χ2 = 3.914, P = 0.048), Child–Pugh score (χ2 = 5.491, P = 0.019), phenotype of peripheral blood monocyte (Treg) (χ2 = 5.015, P = 0.025), and results of bile bacterial culture (χ2 = 65.381, P < 0.001). Multivariate analysis suggested that high-risk factors were drainage style, Child–Pugh score, and results of bile culture. Conclusions: The risk factors of biliary infection after PTBD included: age, site of obstruction, drainage style, tumor stage, hemoglobin, Child–Pugh score, phenotype of peripheral blood monocyte (Treg), and results of bile culture. It was further concluded that drainage style, Child–Pugh score, and results of bile culture were independent risk factors.

There is an increasing rivalry between percutaneous transhepatic (PTBD) vs. endoscopic ultrasound-guided biliary drainage (EUS-BD) as rescue techniques after failed endoscopic retrograde cholangiography (ERC) access. While EUS-BD procedures hold a bright future, innovations in PTBD technique are still possible and clinically meaningful, at least so, under the a conceptual framework understanding PTBD as a bridging, anatomy-respecting technology for definitive biliary metal stenting. This, however, calls for successful PTBD internalization as a sine qua non. Against this background, here, I present a novel approach of PTBD internalization using a standard triple-lumen papillotome as a stiff catheter for probing and assisting in guidewire cannulation of the route to the duodenum. This is the first report on such re-purposed use of a papillotome, which may be instrumental in fine-tuning contrast media filling and crossing angulations within the biliary system. Taken together, innovative advancements and variations in PTBD technique, such as the presented "antegrade papillotome navigation", may rescue difficult PTBD internalization and, thus, potentially obviate the need for alternative approaches, including pure EUS-BD or even more complex hybrid PTBD-EUS procedures.

BACKGROUND The purpose of this observational cohort study was to assess patient and operator-dependent factors which could have an impact on total fluoroscopy time during ultrasound and fluoroscopy-guided percutaneous transhepatic biliary drainage (PTBD). MATERIAL AND METHODS Between October 2016 and November 2020, 127 patients with malignant biliary obstruction underwent ultrasound- and fluoroscopy-guided PTBD with the right-sided intercostal approach. The initial bile duct puncture was ultrasound-guided in all patients, and the puncture angle was measured by ultrasound. Any subsequent steps of the procedure were performed under continuous fluoroscopy (15 fps). The patients were divided in 2 groups based on the puncture angle: ≤30° (group I) and >30° (group II). In a retrospective analysis, both groups were compared for inter- and intragroup variability, technical success, total fluoroscopy time, and complications. RESULTS In group II, the recorded total fluoroscopy time (232.20±140.94 s) was significantly longer than that in group I (83.44±52.61 s) (P

BACKGROUND AND AIMS: Most patients with pancreatic cancer are diagnosed at a late stage and are not candidates for surgical resection. Many have jaundice requiring biliary drainage, which can be accomplished using ERCP or percutaneous transhepatic biliary drainage (PTBD). To date, no studies have evaluated the impact of ERCP or PTBD on survival among patients with unresectable pancreatic cancer. The aims of our study were to compare overall survival between patients with unresectable pancreatic cancer receiving ERCP with those receiving PTBD, to compare overall survival between patients who received a biliary intervention (ERCP or PTBD) versus those who received no biliary intervention, and to compare secondary outcomes, such as length of hospital stay and costs, between ERCP and PTBD. METHODS: We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results–Medicare database. Patients with known pancreatic cancer were included if they had a pancreatic head mass and/or evidence of biliary obstruction. We used a time-varying Cox proportional hazards model to estimate overall survival of patients receiving ERCP versus PTBD and overall survival among patients who received a biliary intervention versus no biliary drainage. Secondary outcomes included length of hospital stay, costs, and admissions within 30 days. RESULTS: Of 14,808 patients with unresectable pancreatic cancer, 8898 patients (60.0%) underwent biliary drainage and 5910 patients (39.9%) received no biliary intervention. ERCP accounted for most biliary interventions (8271, 93.0%), whereas 623 patients (7.0%) underwent PTBD. In multivariable analysis, ERCP was associated with reduced mortality compared with PTBD (adjusted hazard ratio [aHR], .67; 95% confidence interval [CI], .60-.75). When ERCP or PTBD was compared with no biliary intervention, both procedures were associated with a survival benefit (aHR, .51 [95% CI, .49-.54] and .53 [95% CI, .48-.59], respectively). Compared with patients receiving PTBD, those who underwent ERCP had shorter mean length of hospital stay (7.0 ± 5.7 days vs 9.6 ± 6.6 days, respectively; P < .001) and lower hospital charges ($54,899.25 vs $75,246.00, P < .001) but no significant difference in hospitalization or 30-day readmissions. CONCLUSIONS: ERCP is associated with reduced mortality compared with PTBD in pancreatic cancer patients, highlighting the critical role of ERCP in the management of biliary obstruction from pancreatic cancer.

Dislodged intrabiliary drainage devices, including catheters, endoprostheses, and stents, may further impair drainage and cause various local reactions, vascular and gastrointestinal tract complications. Endoscopic approaches for management of plastic biliary endoprostheses have been extensively discussed. However, in rare cases of fracture of percutaneous transhepatic biliary drainage (PTBD) catheters, only a percutaneous transhepatic technique for retrieving should be applied to avoid further damage by its rigid fragment. We present the adjusted techniques using either a goose neck snare, over-the-wire balloon catheter, or biopsy forceps with image demonstration and reviews. We encountered two patients with PTBD tube fracture and intrahepatic dislodgment. In both patients, percutaneous approaches were used for successfully retrieving and removing the fractured catheter through transhepatic tract: one with the use of a biopsy forceps, another with an inflatable balloon catheter.

To develop a model to predict successful bilirubin decrease following percutaneous biliary drain placement. A total of 257 patients who were identified having undergone percutaneous transhepatic biliary drain placement (PTBD) at our institution between 2002 and 2013 had their medical records and imaging reviewed. Of those, 190 of these patients met criteria and were used in the analysis. A regression model was performed on logarithm-transformed collected variables to predict post-drainage logarithmic transformed total bilirubin levels. A stepwise variable selection method based on Schwarz Bayesian Information Criterion was used to select the most closely associated variables. The model was validated with a Monte Carlo simulation. A short program was developed to calculate the point estimate using the model developed and compared to actual values. The variables that best predicted bilirubin reduction were initial Tbl (PrTbl), INR and ALT. The selected model had a root mean squared error of 0.8. The model had a negative predictive value (PoTbl is below 2 mg/dL) of 83%. PTBD may not achieve decreasing bilirubin in patients with a malignant obstruction. This is an initial model that can help determine which patients may not benefit from PTBD placement. With more patients, the model’s validity can be increased and provide useful clinical determinant to aide patient care.

Background The aim of this study was to investigate the long-term impact of the type of preoperative biliary drainage used for patients undergoing pancreatoduodenectomy for distal cholangiocarcinoma (DCC). Methods A total of 84 patients with DCC who underwent preoperative biliary drainage between June 2000 and December 2016 were divided into groups for whom percutaneous transhepatic biliary drainage (PTBD) (n = 24) or endoscopic biliary drainage (EBD) (n = 60) was used. Results The 5-year overall survival in the PTBD group was significantly worse than that in the EBD group (16.7% versus 52.3%, P = 0.007). After propensity score matching (22 patients in each group), the 5-year overall survival in the PTBD group was still worse than that in the EBD group (13.6% versus 61.2%, P = 0.003). Multivariate analysis revealed that PTBD was independent risk factor for both poor survival (P = 0.028) and peritoneal recurrence (P = 0.018). The incidence of multiple sites at initial recurrence tended to be higher in the PTBD group than in the EBD group (P = 0.080). Conclusions PTBD should not be performed for patients undergoing pancreatoduodenectomy for DCC, except when EBD is contraindicated, as PTBD is significantly associated with shorter survival and peritoneal recurrence.

Background We present a retrospective analysis of our experience with pediatric liver transplantation (LT), focusing on the long-term outcome of percutaneous transhepatic biliary drainage (PTBD) for post-transplant biliary strictures. Methods Fifty-three PTBDs were performed for 41 pediatric recipients with biliary strictures. The median ages at LT and PTBD were 1.4 and 4.4 years, respectively. The median observation period was 10.6 years. Results Post-transplant biliary strictures comprised anastomotic stricture (AS) in 28 cases, nonanastomotic stricture (NAS) in 12, anastomotic obstruction (AO) in 8, and nonanastomotic obstruction (NAO) in 5. The success rate of PTBD was 90.6%, and the 15-year primary patency rate of PTBD was 52.6%. The recurrence rate of biliary strictures after PTBD was 18.8% (9/48), and among the four NAS cases with recurrence, two underwent re-LT. The biliary obstruction rate was 27.1% (13/48). Among the eight cases with AO, five underwent the rendezvous method and three underwent surgical re-anastomosis. Among the five cases with NAO, one underwent re-LT. The recipient survival rate of PTBD treatment was 100%. Conclusions The graft prognosis of AS by PTBD treatment is good and AO is curable by the rendezvous method and surgical re-anastomosis. However, the graft prognosis of NAS and NAO is poor.

OBJECTIVE: To evaluate the factors affecting the length of hospital stay (LOS) after percutaneous transhepatic biliary drainage (PTBD). METHODS: A retrospective review of all patients who had undergone PTBD with or without stenting at a UK specialist centre between 2005 and 2016 was conducted. RESULTS: 692 patients underwent 1976 procedures over 731 clinical episodes for which, the median age was 65 (range 18–100) years, and the median Charlson Index was 3. PTBD was performed for malignant (n = 563) and benign strictures (n = 60), stones (n = 62), and bile leaks (n = 46). The median LOS was 13 (range 0–157) days, and the median interprocedure duration was 9 (range 0–304) days. The median number of procedures per patient was 2 and the median number of days required to complete a set of procedures for a patient (TBID) ranged from 0 to 557 days, with a median of 16 (interquartile range: 8–32) days. Patients with biliary leak had the highest LOS. Biliary stents were mostly placed at the second stage at a median of 6 (range 0–120) days from the first procedure day. Placement of a biliary stent in the first stage of the procedure was associated with shorter LOS (p < 0.001). CONCLUSIONS: Biliary stenting at index procedure reduces LOS, although it is not always technically possible. Patients with bile leak managed with PTBD have longer LOS. ADVANCES IN KNOWLEDGE: This study provides data which can help in appropriate consenting, better planning, and efficient resource utilization for patients undergoing PTBD.

Aims: Aim of this study is to describe a multicenter experience on percutaneous transhepatic biliary drainage (PTBD) performed with ultrasound-guidance to access the biliary tree, focusing on safety, effectiveness and radiation dose exposure; differences between right- and left-sided approaches have been also evaluated. Methods: This is a multicenter prospective single-arm observational study conducted on patients affected by biliary tree stenosis/occlusion with jaundice and endoscopically inaccessible. The procedures have been performed puncturing the biliary system under US guidance and crossing the stenosis/occlusion under fluoroscopy. Beam-on time and X-ray dose have been evaluated. Results: 117 patients affected by biliary tree stenosis/occlusion not manageable with an endoscopic approach have been included in this analysis. The biliary stenosis/occlusion was malignant in 90.8% and benign in 9.2%. Technical success, considered as positioning of a drainage tube into the biliary tree, was 100%. Overall clinical success, considered as decrease in total bilirubin level after a single procedure, was 95.7%. The overall mean number of liver punctures to catheterize the biliary tree was 1.57. The mean total beam-on time was 570.4s; the mean dose-area product was 37.25Gycm2. No statistical significant differences were observed in terms of technical and dosimetry results according to right-sided and left-sided procedures. Complications rate recorded up to 30days follow-up was 10.8%, all of minor grades. Conclusions: In this series US guidance to access the biliary tree for PTBD was a safe and effective technique with an acceptable low-grade complications rate; the reported radiation dose is low. Graphic abstract: [Figure not available: see fulltext.].

Percutaneous biliary interventions have a well-established role in the management of hepatobiliary diseases. Good outcomes include recognizing and avoiding complications. This section will cover the "standard" technique of percutaneous biliary drainage, pearls to decrease the risk of problems, and approaches to treat those complications in patients undergoing percutaneous transhepatic cholangiography and percutaneous transhepatic biliary drainage.

Background The frequency of isolated biliary candidiasis is increasing in cancer patients. The clinical significance of isolated biliary candidiasis remains unclear. We analyzed the risk factors of biliary candidiasis and outcomes of the patients with unresectable cholangiocarcinoma after percutaneous transhepatic biliary drainage (PTBD). Methods Among 430 patients who underwent PTBD between January 2012 and March 2015, 121 patients had unresectable cholangiocarcinoma. Bile and blood samples were collected for consecutive fungal culture. Results The study cohort included 49 women and 72 men with a median age of 71 years. Multivariate analysis showed that cancer progression (P=0.013), concurrent presence of another microorganism (P=0.010), and previous long-term (>7 days) antibiotic use (P=0.011) were potential risk factors of biliary candidiasis. Chemotherapy was not associated with overall biliary candidiasis (P=0.196), but was significantly related to repeated biliary candidiasis (P=0.011). Patients with isolated biliary candidiasis showed remarkably reduced survival compared with those without [median overall survival (OS): 32 vs 62 days, P=0.011]. Subgroup analysis was also performed. Patients with repeated candidiasis had markedly decreased survival compared with those with transient candidiasis (median OS: 30 vs 49 days, P=0.046). Biliary candidiasis was identified as a poor prognostic factor by univariate and multivariate analyses (P=0.033). Four cases of repeated candidiasis (4/19, 21%) showed Candida species in consecutive blood culture until the end of the study, but others showed no candidemia. Conclusions Isolated biliary candidiasis may be associated with poor prognosis in patients with unresectable cholangiocarcinoma. Especially, repeated biliary candidiasis may have the possibility of progression to candidemia. We suggest that biliary dilatation treatment or antifungal agents might be helpful for patients with biliary candidiasis.

Although Streptococcus pneumoniae is an important pathogen of humans, pneumococcal cholangitis is rare because of the rapid autolysis of S. pneumoniae. The aim of this case series was to review patients with bile cultures positive for S. pneumoniae. This study was a single center retrospective case series review of patients with S. pneumoniae in their bile at a tertiary-care cancer center between September 2002 and August 2015. Subjects consisted of all patients in whom S. pneumoniae was isolated in their bile during the study period. Bile specimens for culture were obtained from biliary drainage procedures such as endoscopic retrograde biliary drainage, endoscopic nasobiliary drainage, and percutaneous transhepatic biliary drainage. There were 20 patients with bile cultures positive for S. pneumoniae during the study period. All patients presented with extrahepatic obstructive jaundice due to hepatopancreatobiliary tumors. Nineteen of 20 patients underwent the placement of plastic intrabiliary tubes. The mean time between the first-time drainage and the positive culture was 26 days (range 0–313 days). Although 12 of 20 patients met our definition of cholangitis, 5 were clinically treated with antibiotics based on a physician's assessment of whether there was a true infection. The present study is the largest case series of patients with S. pneumoniae in their bile. Based on our findings, the isolation of S. pneumoniae from bile may be attributed to the placement of biliary drainage devices.

We present a case report of broncho-biliary fistula that developed due to the blockage of biliary stent placed during the management of pancreatic neuroendocrine tumor (pNET); diagnosed on high clinical suspicion, percutaneous cholangiogram and contrast enhanced computed tomography (CECT); and successfully treated with percutaneous transhepatic biliary drainage (PTBD).

Acute biliary conditions include cholangitis, obstruction, and biliary leakage. All these conditions may lead to severe biliary sepsis, which can be life threatening. Infected obstructed cholangitis is a medical emergency that requires active medical therapy and early biliary decompression is recommended. This article provides an overview of the clinical presentations and management of biliary sepsis. The technique, clinical applications, and outcomes of percutaneous transhepatic biliary drainage and those related to gall bladder drainage are highlighted. Future alternatives to conventional biliary drainage are discussed.

Background: Short-term survival rates are reported in the patients undergoing percutaneous transhepatic biliary drainage (PTBD). The purpose of this study was to determine the factors predicting survival following percutaneous biliary drainage. Materials and Methods: The data of 90 patients undergoing PTBD due to malignant biliary obstruction were analyzed retrospectively between January 2009 and November 2014. Results: The median age of the patients were 64 years. Fifty-one (57%) of the patients were male. Median survival following PTBD was 44 days. Survival rates at 1 month, 3 months, and 6 months following PTBD were 58%, 33%, and 8.9%, respectively. Multivariate Cox's regression analysis showed that platelet (PLT) count is significantly associated with predictors of survival; the other factors affecting survival were receiving chemotherapy following PTBD, liver metastasis, and serum albumin levels. Conclusion: Lower serum PLT level following PTBD is associated with the short-term survival. Survival of patients who are not able to receive chemotherapy after PTBD, having a low level of serum albumin, and patients with liver metastasis were shorter.