Percutaneous management of malignant biliary disease

Abstract

Percutaneous biliary interventions have established their role in the management of benign and malignant biliary disease. There are limited data comparing procedures performed by gastroenterologists and interventional radiologists in managing malignant biliary obstruction. Endoscopic procedures performed by gastroenterologists are not completely benign with reported complications ranging from 2% to 15%. It is important that gastroenterologists and interventional radiologists collaborate to form algorithms for management of malignant biliary obstruction which provide safe and efficacious care to these patients. K E Y W O R D S biliary intervention, biliary stenting, interventional radiology, percutaneous transhepatic cholangiography 2.2 | Indications Cholangitis: If a patient has fever, right upper quadrant pain, and jaundice, there should be a very high suspicion of cholangitis. Biliary drainage can help prevent sepsis which can be catastrophic. Pruritus: Itching may also be a reason to perform a procedure. Most patients with pruritus due to biliary obstruction have a diurnal variation of itch intensity (worst in the evening). Itching worsens with heat and most often affects limbs (palms of the hands and soles of the feet). Pruritus related to biliary obstruction is likely caused by lysophosphatidic acid. 1 Drainage of even a small portion of the biliary tree can decrease/resolve pruritus. Anorexia: Obstructive jaundice can alter taste and decrease appetite. Anorexia has been associated with hyperbilirubinemia, increased alkaline phosphatase, and increased cholecystokinin levels. 2 Drainage can improve appetite. Presurgical drainage: Patients with resectable malignancy without cholangitis should not be drained. A 75-patient randomized prospective trial demonstrated no improvement in 30-day mortality in patients who had been drained compared to those who had not been drained. A systematic review of randomized trials on J Surg Oncol. 2019;120:45-56. wileyonlinelibrary.com/journal/jso

Endoscopic Accessibility of the Biliary System in the Postoperative Situs

“…Afterward, a guidewire is advanced through the needle followed by serial dilatation. This access can be used for diagnostic cholangiography, brush biopsy of stenosis, external or internal-external biliary drain, stent placement, or even cholangioscopy and laser lithotripsy [1,15]. Therapeutic success rates in malignant biliary obstruction range between 61% and 79% [15].…”

“…This access can be used for diagnostic cholangiography, brush biopsy of stenosis, external or internal-external biliary drain, stent placement, or even cholangioscopy and laser lithotripsy [1,15]. Therapeutic success rates in malignant biliary obstruction range between 61% and 79% [15]. Evidence with percutaneous lithotripsy for managing choledocholithiasis in patients after RYGB is limited.…”

Percutaneous Biliary Endoscopy

“…33 These have also been created in patients with malignant biliary diseases. 34,35 Percutaneous transjejunal access (PTJA) without surgical affixation has also been described. 36,37 PTJA (with or without the modified Hutson loop) provides an avenue to perform cholangiography and cholangioscopy for diagnostic and therapeutic interventions of the biliary tree in patients with prior Roux-en-Y hepaticojejunostomy.…”

Future Directions of Percutaneous Biliary Interventions

“…10 These have been created in patients undergoing living donor liver transplants and patients with malignant biliary disease. 5,11,12 Advancing 10-Fr scopes through these accesses allows for visualization of biliary-enteric anastomoses and perform appropriate interventions.…”