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Hepatocellular carcinoma represents a major global health burden. Its treatment is often complicated by the anatomical location of tumors, which can lead to adverse outcomes. Radiofrequency ablation has recently gained attention as a safe method for treating hepatocellular carcinoma, but only in tumors that are not adjacent to bile ducts. Here, we report a new method for cooling the bile duct during radiofrequency ablation therapy, in which the outer jacket of an elastor needle was fixed and flash-cooled with chilled saline. This method was applied in a patient with hepatocellular carcinoma tumors near the main bile duct. The patient underwent successful radiofrequency ablation with bile duct cooling. The advantages of this method include low medical cost, simpler securing of nonexpanded bile ducts, and simultaneous removal upon termination of the radiofrequency ablation therapy. Bile duct complications associated with radiofrequency ablation typically have delayed onset. Computed tomography examination 2 months after treatment showed no bile duct injury in this case.

Perkutane Interventionen der Gallenwege und der Gallenblase sind fester Bestandteil in der Diagnostik und Therapie von Gallenwegerkrankungen. Sie zeigen mit technischen Erfolgsraten von bis zu 99 % sowie Komplikationsraten von max. 26 % gute Ergebnisse. Die Indikationen reichen dabei von der Darstellung der Gallenwege bis hin zu therapeutischen Eingriffen wie Drainagen und Stents. Angewendet werden perkutane Interventionen, wenn endoskopische Verfahren nicht moglich oder ausgeschopft sind. Dieser Ubersichtsartikel gibt einen Uberblick uber den aktuellen Stand sowie die Bandbreite perkutaner Interventionen der Gallenwege/Gallenblase und beschreibt die technische Durchfuhrung der grundlegenden Gallenweginterventionen. Interventionen der Gallenwege und der Gallenblase sind sichere und effektive Verfahren in der Behandlung von benignen und malignen Gallenwegstrikturen, postoperativen Komplikationen sowie Risikopatienten mit Cholezystitis.

Background & aims Biliary strictures are common complications after orthotopic liver transplantation. Endoscopic retrograde cholangiography evolved as standard and percutaneous transhepatic cholangiodrainage as alternative therapy. This study analysed predictors of long-term success of biliary strictures after endoscopic retrograde cholangiography and/or percutaneous transhepatic cholangiodrainage and its impact on patient survival. Methods All adult patients with biliary strictures receiving endoscopic retrograde cholangiography and/or percutaneous transhepatic cholangiodrainage between 2009 and 2015 at the University Medical Center Hamburg-Eppendorf were retrospectively analysed. Potential predictors of long-term success (≥12 months) were identified by univariate and logistic regression analyses. Patient survival was analysed by Kaplan-Meier method and log-rank test. Results Hundred and sixteen patients were treated with endoscopic retrograde cholangiography and/or percutaneous transhepatic cholangiodrainage, including 67 patients with anastomotic strictures, 22 with nonanastomotic strictures and 27 with both stricture types. Eighty-five patients received endoscopic retrograde cholangiography, 17 percutaneous transhepatic cholangiodrainage and 14 both techniques. Long-term success was achieved in 60 patients (52%). Predictors of treatment failure were a preinterventional C-reactive protein >8 g/dL in anastomotic strictures (P = 0.039) and a body mass index ≤21 kg/m2 in nonanastomotic strictures (P = 0.021). In patients who received endoscopic retrograde cholangiography only, balloon dilatation of anastomotic strictures with larger diameters favoured success (P = 0.015). Achievement of long-term success was associated with prolonged patient survival in anastomotic strictures (P = 0.036) and nonanastomotic strictures (P = 0.025), but not in combined strictures (P = 0.739). Conclusion In post-orthotopic liver transplantation biliary strictures treated by endoscopic retrograde cholangiography and/or percutaneous transhepatic cholangiodrainage, patient BMI and preinterventional C-reactive protein may influence prognosis. Endoscopic retrograde cholangiography with larger balloon diameter may favour success in anastomotic strictures. Long-term success by endoscopic retrograde cholangiography and/or percutaneous transhepatic cholangiodrainage is associated with superior survival in patients with anastomotic strictures and nonanastomotic strictures only.

Objective The aim: Is to determine the optimum duration of percutaneous transhepatic cholangiodrainage depending on the duration of obstructive jaundice and the baseline total bilirubin level in patients with benign and malignant common bile duct diseases complicated by obstructive jaundice. Patients and methods Materials and methods: The experience of applying percutaneous transhepatic cholangiodrainage was combined for 88 patients with common bile duct diseases complicated by obstructive jaundice. The patients were divided into three groups: the Group 1 included 15 patients (17.1%) with benign common bile duct diseases, the Group 2 included 11 patients (12.5%) with resectable cholangiocarcinomas, and the Group 3 included 62 patients (70.4%) with unresectable cholangiocarcinomas. To determine optimal terms of biliary decompression using percutaneous transhepatic cholangiodrainage, the Poisson process was applied, and, to be more precise, the quasi-Poisson distribution. Results Results: It was found that the reduction of total bilirubin was the fastest in Group 3 patients. It took these patients an average of 7-8 days to reduce total bilirubin to 50 μmole/l. In Group 1 patients, the process is somewhat slower. The duration of biliary decompression in this category of patients averages 10-12 days. For Group 2 patients, biliary decompression requires at least 12 days. Conclusion Conclusions: Using the Poisson process, or, to be more precise, the quasi-Poisson distribution, we managed to determine the optimum duration of biliary decompression using percutaneous transhepatic cholangiodrainage depending on the obstructive jaundice duration and the baseline total serum bilirubin.

Percutaneous transhepatic cholangiodrainage is an intervention for obstructive jaundice that, although effective in decreasing bilirubin levels, often leads to depletion of regular bile acids that subsequently cause malabsorption, diarrhea, and acute kidney injury. Bile reinfusion (BR) is a method of enteral refeeding of biliary secretions to replenish innate bile acids to the patient. In addition, BR is a low-cost alternative to exogenous bile acid replacement and abates the need for inpatient fluid resuscitation. We report oral BR in a patient with percutaneous transhepatic cholangiodrainage due to choledocholithiasis and review the literature on BR.

Introduction Both benign and malignant diseases of common bile ducts (CBD) become the reason of obstruction. The aim of the study was to determine the optimal duration of percutaneous transhepatic cholangiodrainage (PTCD) depending on the duration of obstructive jaundice (OJ) and the initial level of total serum bilirubin. Methods The experience of using PTCD in 88 patients with diseases of CBD complicated by OJ for the period 2011-2017 were divided into three groups: the first (1) - 15 (17.1%) patients with benign diseases of CBD, the second (2) - 11 (12.5%) patients with resectable cholangiocarcinomas, and the third (3) - 62, 4%) patients with unresectable cholangiocarcinomas. Causes of OJ: choledocholithiasis in 6 (6.8%), strictures of CBD in 2 (2.3%) and cholangiocarcinomas of different localization in 73 (82.9%) patients. The optimal timing of biliary decompression was determined by PTCD, the Poisson process (poisson) was used, and more precisely as the quasipoisson distribution (quasipoisson), which reflects the process of reducing total serum bilirubin. Results It was determined that the fastest decrease in total bilirubin occurs in patients of group 3, enough 7-8 days to reduce total bilirubin to 50 μmol/L. In patients of group 1, the duration of biliary decompression is 10-12 days. For patients in group 2, biliary decompression requires at least 12. Conclusions Using the Poisson process (poisson), or more precisely the quasi-Poisson distribution (quasipoisson), it was possible to determine the optimal duration of biliary decompression by PTCD depending on the duration of OJ and the initial level of total serum bilirubin.

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold-standard modality for diagnosis and therapy of bilio-pancreatic disease. In particular, peroral cholangiography (POCS) is a useful modality not only for diagnosing biliary disease, but also for therapeutic procedures such as electrohydraulic lithotripsy. The SPY-DS single-operator cholangioscope has recently become available, and offers favorable visualization, a wide view, suction function and a larger accessory working channel. However, if the duodenoscope cannot be advanced into the ampulla of Vater for reasons such as surgical anatomy, POCS cannot be performed. On the other hand, percutaneous transhepatic cholangiodrainage (PTCD) has been developed as an alternative endoscopic ultrasound-guided approach to the biliary tract. Peroral transluminal cholangioscopy (PTLC) using SPY-DS is a novel approach. Because transluminal interventional procedures under endoscopic ultrasound guidance have recently been developed, our technique may have clinical impact for selected cases.

Objectives Perihilar cholangiocarcinoma (Klatskin tumor) is a rare tumor entity, which is diagnosed late due to uncharacteristic symptoms. The therapeutic strategy for cure is still liver resection. Liver transplant in cases of locally irresectable tumors represents an alternative potential curative therapy for a select group of patients. Materials and methods We present our data of 22 patients with irresectable Klatskin tumors who received transplants between 1996 and 2015. We analyzed relevant prognostic factors for the selection of patients to be transplanted to ensure an acceptable overall survival and reviewed known and established selection criteria. Results Four factors (age, tumor size, serum level of carbohydrate antigen 19-9, percutaneous transhepatic cholangiodrainage) could be detected for possible patient selection. Positive lymph node status and advanced tumor stage according to the Union for International Cancer Control were confirmed as negative prognostic factors for survival after transplant. Conclusions Liver transplant is a curative therapy for selected patients with irresectable Klatskin tumors, but further prospective studies are urgently needed.

We report here the rare case of a 61-year-old man with multiple organ dysfunction caused by an aspirin overdose (4 g orally). The patient presented with a fever that reached 39.2 °C, a peptic ulcer, and massive upper gastrointestinal bleeding. His blood test results were as follows: white blood cell count, 1.8 × 10(9)/L; absolute lymphocytes, 0.4 × 10(9)/L; absolute neutrophils, 1.2 × 10(9)/L; and electrolyte disturbances. A computed tomography (CT) scan showed evidence of bilateral inferior pulmonary infection and acute pancreatitis. Thick dark bile with visible floccule was drawn via a percutaneous transhepatic cholangiodrainage (PTCD). Klebsiella pneumoniae was detected in microbiological bile tests. Two years later, the patient died of chronic liver failure.

Biliary complications after hepatopancreaticobiliary surgery can have severe consequences for the long-term quality of life of patients. Adequate and timely diagnosis of the underlying problem by an experienced surgeon is essential. Ultrasonography, computed tomography, contrast-enhanced fluoroscopy of drains and endoscopic retrograde cholangiopancreatography (ERCP) are helpful examinations that can be employed in a step-wise approach. Early re-do surgery is indicated in the initial postoperative course. Interventional methods, such as ERCP and percutaneous transhepatic cholangiodrainage ( PTCD, plus stents and drains) offer a variety of additional therapeutic options that should be used by the experienced interventionalist in a patient-tailored interdisciplinary fashion.

Extensive controversies exist over the use of preoperative biliary drainage preceding radical resection of hilar cholangiocarcinoma. This study assessed the effectiveness and safety of percutaneous transhepatic cholangiodrainage (PTCD) with bile re-infusion in the preoperative optimization of hilar cholangiocarcinoma patients.Eligible hilar cholangiocarcinoma patients received preoperative PTCD with bile re-infusion (treatment group, n = 56) through a nasoduodenal tube for 2 weeks, and the control group (n = 60) received conservative treatment alone. Operable patients were assigned to undergo either a radical or palliative resection. The outcome measures included the overall resection rate, R0 resection rate, surgical morbidity rate and 1-year and 5-year overall survival rates.The treatment group exhibited a significant decrease in serum bilirubin levels after PTCD with bile re-infusion. The overall resection rate was significantly higher in the treatment group than in the control group (85.5% vs. 65.0%, P0.05), and the palliative resection rate was also significantly higher in the treatment group (53.5% vs. 35.0%, P0.05). However, the R0 resection rate was comparable between the 2 groups (32.1% vs. 30.0%, P0.05). The morbidity rate was significantly lower in the treatment group than in the control group (29.1% vs. 51.3%, P0.05). One-year and 5-year survival rates were similar between the 2 groups (69.6% vs. 66.7%, P0.05; 5.3% vs. 3.6%, P0.05).Preoperative PTCD with bile re-infusion improves the resection rate and shows a good safety profile in patients with hilar cholangiocarcinoma.

BACKGROUND: Capnography provides noninvasive monitoring of ventilation and can enable early recognition of altered respiration patterns and apnea.OBJECTIVE: To compare the detection of apnea and the prediction of oxygen desaturation and hypoxemia using capnography versus clinical surveillance during procedural sedation for percutaneous transhepatic cholangiodrainage (PTCD).METHODS: Twenty consecutive patients scheduled for PTCD were included in the study. All patients were sedated during the procedure using midazolam and propofol. Aside from standard monitoring, additional capnographic monitoring was used and analyzed by an independent observer.RESULTS: The mean (± SD) cumulative duration of apnea demonstrated by capnography was significantly longer than the mean cumulative duration of clinically detected apnea (207.5±348.8 s versus 8.2±17.9 s; P=0.015). The overall number of detected episodes of apnea was also significantly different (113 versus seven; P=0.012). There were 15 events of oxygen desaturation (decrease in oxygen saturation [SaO2] ≥5%), which were predicted in eight of 15 cases by capnography and in one of 15 cases by clinical observation. There were three events of hypoxemia (SaO2CONCLUSION: Capnographic monitoring was superior to clinical surveillance in the detection of apnea and in the prediction of oxygen desaturation during procedural sedation for PTCD.

Background Duct-to-duct biliary reconstruction (DD) is currently a standard procedure in adult live donor liver transplantation (LDLT). Its pediatric feasibility, however, has rarely been reported. The goal of this study is to assess the incidence and treatment of biliary complication after pediatric LDLT with DD or Roux-en-Y hepaticojejunostomy (RY). Method Sixty children received LDLT between November 2005 and June 2008, and their database was reviewed. Results Biliary reconstruction was achieved with DD in 14 patients and with RY in 46 patients with mean follow-up period of 26.0 and 22.3 months, respectively. The incidence of biliary leakage in the DD and RY groups was 7.1% and 8.7%, respectively, and that of stricture was 28.6% and 10.9%, respectively; but the differences were not statistically significant. Biliary stricture in the DD group tended to require revision surgery with RY and longer treatment with percutaneous transhepatic cholangiodrainage compared with that in the RY group. Conclusion Theoretical advantages of DD over RY were not confirmed in this study. Duct-to-duct biliary reconstruction tended to encounter more biliary complications, especially stricture, with more difficulty in treating it than RY. Roux-en-Y hepaticojejunostomy seems preferable to DD in the setting of pediatric LDLT, but DD must be considered when making new Roux-en-Y limb seems impossible or troublesome owing to abdominal dense adhesion or short bowel syndrome.

症例は60歳の男性で，25年前に胃潰瘍のため広範囲胃切除・Billroth II法再建術を施行されていたが，残胃に早期癌が認められ，残胃全摘・Roux-Y法再建術を施行した．術直後に挙上空腸腸間膜からの出血にて再開腹を行った．術後下腹部膨満を認め，経過観察していたが術後12日目の血液検査にて肝機能障害・高アミラーゼ血症認められ，腹部CTにて十二指腸の著明な拡張像が見られ，急性輸入脚閉塞症と診断した．肝内胆管の軽度拡張も見られたため術後15日目に経皮経肝胆道ドレナージを用いて十二指腸の減圧を行った．狭窄部位はTreitz靭帯付近で，持続減圧にて狭窄は徐々に改善し，ドレナージ後35日目にはチューブを抜去しえた．輸入脚閉塞症は早期に診断し，適切な治療法を選択しないと致命的な経過をたどる重篤な合併症であるが，経皮経肝胆道ドレナージは非手術療法として有効な一手段と思われた．

Many studies have reported methods of cell collection involving percutaneous transhepatic cholangiodrainage (PTCD) and fine-needle aspiration cytology for the diagnosis of gallbladder disease. However, few studies have described the use of a transpapillary approach, i.e., endoscopic transpapillary catheterization into the gallbladder (ETCG). In this study, we analyzed cells collected by ETCG to evaluate its usefulness in the cytological diagnosis of gallbladder disease. The subjects were 19 patients who had undergone ETCG for the diagnosis of gallbladder disease. Of these patients, 11 and 8 had gallbladder cancer and benign gallbladder disease, respectively. We also evaluated the diagnostic accuracy of PTCD cytology performed in 15 patients with gallbladder cancer. Specimens were cytologically diagnosed as normal or benign, indeterminate, suspected malignancy, malignant, and inadequate in 47% (9/19), 11% (2/19), 0% (0/19), 37% (7/19), and 5% (1/19) of patients, respectively. Specimens were diagnosed as malignant, indeterminate, normal or benign, and inadequate in 7, 2, 1, and 1, respectively, of the 11 patients diagnosed with gallbladder cancer. The sensitivity and specificity of ETCG cytology were 78 and 100%, respectively, whereas the diagnostic accuracy of PTCD cytology was 20% (3/15). None of the patients developed complications of ETCG. Despite its technical difficulty, ETCG for bile cytology allows the collection of adequate cell numbers from patients with benign disease or gallbladder cancer and facilitates a cytological diagnosis, making it a useful method for collecting cells. Diagn. Cytopathol. 2009. © 2009 Wiley-Liss, Inc.

Fallbericht: Ein 68-jahriger Patient stellte sich aufgrund eines schmerzlosen Ikterus und einem Gewichtsverlust von 5 Kilogramm in unserer Klinik vor. 4 Jahre zuvor wurde bei symptomatischer Cholecystolithiasis eine laparoskopische Cholecystektomie durchgefuhrt. Die ERCP zeigte eine hochgradige Stenose des Ductus hepatocholedochus mit dem dringenden radiomorphologischen und cholangioskopischen Verdacht auf einen Hepaticusgabeltumor im Stadium Bismuth IV mit Infiltration beider Hepaticusaste. Trotz wiederholter Biopsien war zu keinem Zeitpunkt ein bosartiges, stromainvasives Wachstum nachweisbar. Zur suffizienten biliodigestiven Dranage wurde eine perkutane transhepatische Cholangiodranage mit Einlage einer Yamakawaprothese durchgefuhrt. Auch in wiederholten Biopsien zeigte sich keinerlei Anhalt fur Malignitat. Nach einjahriger Therapie war eine Stenose des Gallengangssystems nicht mehr nachweisbar und die prothetische Versorgung konnte beendet werden.Schlussfolgerung: Der geschilderte Fall zeigt die oftmals schwierige Differenzierung zwischen einer benignen und malignen Stenose der Gallengange. Es sollte durch die Kombination von mehreren Untersuchungsmethoden versucht werden eine sichere Diagnose zu stellen. Oftmals kann eine Klarung jedoch nur durch den Verlauf erbracht werden. Case report: A 68-year-old patient presented himself in our department on account of a painless jaundice and a weight loss of 5 kg. 4 years earlier a laparoscopic cholecystectomy had been performed because of a symptomatic cholecystolithiasis. The ERCP showed a high degree stenosis of the common bile duct with a urgent radiomorphological and cholangioscopic suspicion of a tumor on the fork of the ductus hepaticus (stage Bismuth IV) with an infiltration of both bile ducts. Despite repeated biopsies no malignant, stromainvasive growth was detectable at any time. To ensure a sufficient biliodigestive drainage, a percutaneous transhepatic cholangiodrainage with insertion of a Yamakawa-prothesis was performed. Repeated biopsies again showed no signs of malignity. After one year of therapy a stenosis of the bile duct could not longer be detected and the prothetic care could be terminated.Conclusion: The case described shows the often difficult differentation between a benign and a malign bile duct stenosis. A combination of examination methods should be attempted in order to make a reliable diagnosis. A clarification, however, can often only be provided with the course of the illness.

Background and study aims. MRI-guided procedures combine high-quality imaging with lack of radiation. Percutaneous transhepatic cholangiodrainage under real-time MRI guidance (MRI-PTCD) seems promising, allowing targeted puncture and avoiding multiple blind passes and use of contrast, which are associated with standard PTCD’s heaviest complications. Patients and methods. Aim of this study was to investigate the feasibility of MRI-PTCD in three outbred piglets. Obstructive cholestasis was induced by common bile duct ligation. Two days later, MRI-PTCD was performed (open MRI, 1.0 Tesla) with prototype MRI-compatible accessories. Visualization was achieved with a balanced steady-state free precession real-time sequence (bSSFP: 0.75 frames/s, TR/TE [ms]: 7.2/3.6; flip angle: 45; 200 200 matrix size; resolution: 1.3 1.3 mm 2 , slice thickness: 7 mm). Cannulation of the bile ducts was followed by placement of Yamakawa drainages. Results. Twelve punctures were performed (four per animal, 10/12 successful); in 2/10 the bile ducts could not be cannulated. Animal survival was 100% and no significant complications occurred. Conclusions. Initial data show that MRI-PTCD can be successfully performed. This may lead to establishment of a new optimized PTCD technique compared to the standard approach under fluoroscopy.

In bile duct carcinoma (BDC) patients, bile aspiration cytology (BAC) is an established method for cytodiagnosis. However, almost all previous reports investigated the biliary strictures caused not only by BDC but also by gallbladder and pancreatic carcinomas. Therefore, BAC in BDC patients only has not yet been investigated sufficiently. The aim of this study was to evaluate the actual sensitivity of BAC and to evaluate the factors that affect positive yields of BAC in patients with defined BDC. Data on 47 consecutive patients with definite BDC, who underwent BAC via endoscopic nasobiliary drainage (ENBD) or percutaneous transhepatic cholangiodrainage (PTCD), were retrospectively collected. Fourteen factors were studied for association with positive BAC. The number of cytological samplings ranged from 1 to 14 times. The cumulative diagnostic yield was 72.3% (34/47), and 32 positive results were obtained at a maximum of six samplings. Independent factors associated with positive BAC were perihilar location, stricture length ≥2 cm, and macroscopic papillary type. In BDC patients with ENBD or PTCD, repeated BAC is useful, and six times was the optimum number of repeat samplings. Although the sensitivity of BAC is not sufficient for the preoperative diagnosis of malignant biliary stricture, the three independent factors noted above predict positive yields and indicate whether or not BAC should be repeated up to six times.

Aims To assess percutaneous transhepatic cholangiodrainage (PTCD) under real-time MRI-guidance and compare it to procedures performed under fluoroscopy. Methods We developed an in vitro model for MRI-guided and conventional PTCD, using an animal organ set including liver and bile ducts placed in an MRI-compatible box and tested it in a 1.0-Tesla open MRI-scanner. Prototype 18G needles and guide wires, standard guide wires, dilatation bougies, and drainages were used (MRI-compatible). MRI-visualization was by means of a bFFE real-time sequence using a surface coil (Flex-L). Outcome measurements were success rates and time needed for bile duct puncture using real-time MRI-guidance versus conventional radiologic methods in the model. Cannulation and drainage placement were also analysed. Results Fifty MRI-guided experiments were performed, leading to rapid (mean: 43 s, range: 15–72 s) and successful puncture and cannulation in 96% of procedures. Median drainage placement time was 321.5 s (range: 241–411 s). In 35 control experiments under fluoroscopy, puncture success was 69%, whereas times were significantly longer (mean 273 s, range 45–631 s). Conclusions Initial in vitro experience shows that PTCD can be successfully and rapidly performed under real-time MRI-guidance and demonstrates improved performance compared to the conventional radiologic approach.

We present our experience with contrast-enhanced ultrasound-guided percutaneous transhepatic cholangiodrainage in eight patients with obstructive jaundice and failure of conventional endoscopic retrograde cholangiography. The intraductal application of the ultrasound contrast agent led to sufficient cholangiography in all patients. In one patient, after accidental dislocation of the bile duct drain, the leakage could be detected by demonstration of the passage of contrast agent into the perihepatic peritoneal space. Further studies are necessary to evaluate this new technique in a larger numbers of patients.

Purpose: The aim of this study was to establish the optimal management strategy of congenital biliary dilatation (CBD) in early infancy. Methods: Over the last 15 years, 14 patients with CBD in early infancy (within 5 months), including 3 antenatally diagnosed patients, were treated in the authors' department. Of the 14 patients, 7 (50%) underwent early definitive surgery (E group), and the other 7 (50%) underwent delayed primary definitive surgery after percutaneous transhepatic cholangiodrainage (PTCD; D group). Both groups were compared retrospectively using clinical data. Results: Pretreatment status and backgrounds of the patients were clinically homogeneous between the 2 groups. The total length of hospital stay was significantly longer in the D group. As short-term complications, 1 patient in the E group was compromised with hepatolithiasis, and 3 patients in the D group were compromised with catheter-related complications. Other clinical data, such as age at definitive surgery, blood loss, pathologic fibrosis of the liver, jaundice-free day, and long-term complications were not significantly different between the 2 groups. Conclusions: The authors propose that the standard of management should be early definitive surgery with wide anastomosis before 2 months of age. However, PTCD might be used under strict consideration of indication and careful management for patients with extremely poor surgical risk. J Pediatr Surg 37:1173-1176. Copyright 2002, Elsevier Science (USA). All rights reserved.

Pericardiocentesis with a needle attached to a probe was performed under two-dimensional echocardiographic guidance in 9 patients with pericardial effusion after cardiac operations. The first 5 mm of the tip of a puncture needle for percutaneous transhepatic cholangiodrainage is scratched with a scalpel to give the tip high echo intensity. When the probe is placed on the skin, the direction of puncture at that probe angle appears automatically on the monitor.

Five cases of intrahepatic biliary cyst or cystic dilatation and one suspicious case were found (6.4%) among 93 survivors of biliary atresia. The age at manifestation of such cysts ranged from 6 months to 12 years. These cysts or cystic dilatations were treated surgically in two cases, by percutaneous transhepatic cholangiodrainage (PTCD) in two, and not treated in one. Four patients are alive; one died of biliary atresia. Twenty-nine well-documented cases of intrahepatic biliary cyst were found in the literature, including five treated by the authors. The modes of dilatation were as follows: type A, noncommunicating cyst; type B, cyst with tiny communication with the intestinal loop; and type C, cystic dilatation. Clinical symptoms were fever, jaundice, acholic stool, and "cholangitis." Nineteen patients (66%) had symptoms within 4 years after the Kasai operation (first group); the modes of dilatation were mostly types A and B. However, in five of six patients with type C dilatation, symptoms developed after 10 years of age (second group). The prognosis for the second group appears poor because the condition of the liver worsens once cystic dilatation develops.

This case report describes a patient with an unusual type of biliary atresia that precluded the Kasai operation but who survived for 2 years and 6 months with percutaneous transhepatic cholangiodrainage (PTCD) and was successfully bridged to liver transplantation. PTCD is recommended when there is no bile excretion after a Kasai operation.