Biliary stone interventions Solved on SIR Connect
By Vijay Jaswani, MD, Jackson Bennet, MD, Patrick Moran, MD, Sudhen B. Desai, MD, FSIR
Original post, lightly edited for flow:
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I have a patient who presented with choledocholithiasis and sepsis. Due to lack of endoscopic retrograde cholangiopancreatography (ERCP) at my hospital, IR was consulted for percutaneous biliary drainage. I placed an internal-external drainage catheter. The patient was then sent out for ERCP and stone extraction; however, when he returned for removal a few weeks later, he had residual common bile duct (CBD) stones. The patient has not been able to see a GI for repeat ERCP, and he is frustrated and demanding tube removal. I explained the risks of removing the tube with stones still in place, but he’s pretty insistent. What would you do?
Please elaborate on the specific patient background and presentation in this case. Vijay Jaswani, MD: Patient is a 72 y/o who presented with epigastric pain, nausea and vomiting. A CT of the abdomen with IV contrast showed dilated intrahepatic ducts and dilated common bile duct to 12 mm. Patient was febrile, tachycardic and had elevated total bilirubin to 6.8. MRI/MRCP showed a distended gallbladder with innumerable calculi and multiple calculi obstructing the distal common bile duct. Given the patient’s sepsis and lack of ERCP capabilities at our institution, the patient was started on IV antibiotics and IR was consulted for urgent percutaneous biliary drainage and a drainage catheter was placed.
Two months later, the patient returned for a drain study to evaluate possible removal. An over-the-wire cholangiogram showed multiple filling defects in the common bile duct consistent with retained vs. new stones. Per discussion with the endoscopist, the postprocedure cholangiogram did not show these stones. However, visualization was limited secondary to presence of the biliary drainage catheter, which was not removed during the procedure.
What are the different types of biliary interventions that IRs can offer? VJ: IRs can offer multiple biliary interventions:
AUTHOR NAME AND CONTACT INFORMATION
Vijay Jaswani, MD Chief of Interventional Radiology One Brooklyn Health Brooklyn, NY
• Percutaneous cholecystostomy (calculous or acalculous cholecystitis, patient is a nonsurgical candidate)
• Percutaneous biliary drainage (PTBD) with placement of external or internal- external biliary drain (septic biliary obstruction/cholangitis, malignant biliary obstruction)
• Percutaneous biliary stenting (malignant biliary obstruction)
• Percutaneous biliary stone extraction
When placing a PTBD when do you consider internalization either via external/internal biliary drain or stenting? What specific methods, approach or techniques do you find useful in performing these cases? VJ: Internalization is always preferred as it minimizes electrolyte and fluid imbalances potentially caused by external biliary drainage and increases patient comfort due to ability to cap or eliminate external drainage bag. In terms of approach, after a suitable target is identified on ultrasound, a 21- or 22-gauge needle is inserted, and a careful injection of contrast is performed in two projections to identify the bile ducts. Once access is obtained, an 0.018-in wire is advanced into the bile ducts, and a triaxial set can be used to help establish a working 0.038-in wire into the bile ducts/ small bowel. As a helpful tip, it is often useful to access nondilated biliary systems with assistance of a guidewire. I also typically cross malignant obstructions with an angled catheter and a hydrophilic wire, after which an 8- to 10-French drain is placed under moderate sedation or anesthesia, as it’s typically painful for the patient. Once bilirubin is normalized and the patient can tolerate a capped drain without pain or fever, an internal biliary stent can then be placed.
In general, for patients with biliary drains, how do you follow up with them and when do you decide to remove the drain? VJ: After 4–6 weeks, the patient is brought back to IR for a tube study. For percutaneous cholecystostomy, the tube can be removed after confirming
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