Our experience with percutaneous transhepatic cholangiography in 46 cases is presented and compared with other series. The technique is safe, simple and accurate and can play a major role in the early diagnosis of obstructive jaundice.S. Afr. Med. J., 48, 637 (1974)

Bass, E.M.

Goldin, A.R.

English

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30 March 1974 S.A. MEDICAL JOURNAL 637Percutaneous Transhepatic CholangiographyA. R. GOLDIN, E. M. BASSSUMMARYOur experience with percutaneous transhepatic cholangio-graphy in 46 cases is presented and compared withother series. The technique is safe, simple and accurateand can play a major role in the early diagnosis of ob-structive jaundice.S. A/I'. Med. J., 48, 637 (1974).Percutaneous transhepatic cholangiography can play amajor role in expediting the early diagnosis of surgicallycorrectable jaundice. The need for this is emphasised bythe fact that in a group of 46 patients the delay betweenthe onset of jaundice and diagnosis ranged from 20 to 90days. Transhepatic cholangiography carried out earlierrather than later could have substantially reduced the costboth in terms of valuable time and of repeated expensivebiochemical examinations.The procedure is simple to perform and experience withthis technique at Groote Schuur Hospital in the past 3 yearshas been extremely encouraging. In this article the indica-tions, technique, results and complications are presented.The indications for performing percutaneous transhepa-tic cholangiography were: (i) to differentiate obstructivefrom hepatocellular jaundice where clinical and biochemi-cal examination was inconclusive; (ii) to define the site andprobable nature of the lesion in known obstructive jaun-dice; (iii) to evaluate jaundice occurring after previousbiliary surgery.METHODProthrombin index (75% minimum) and platelet count(60000 minimum) were evaluated before puncture. Theprocedure was followed by laparotomy in every patientand carried out either under routine premedication orafter 19 mg diazepam (Valium; Roche) intravenously. Allexaminations were carried out by using routine fluoro-scopy facilities equipped with a tilting table, undercouchtube and television monitor. The lateral approach describedby Varela Fuentes et al. 1 and Wiechel' was used in allcases.The site of the puncture (usually the tenth right lateralintercostal space) and diaphragmatic excursion werechecked by screening a marker. Under local anaesthesia a20-mm, 20-gauge B.D. Longdwel Teflon cannula wasDepartment of Radiodiagnosis, Groote Scbuur Hospital, CapeTown1\. R. GOLDL I, )'LB. B.CH. F.e.p. (S.A.), F.F.R.E. M. BASS, M.B. CH.B. D.M.R.D.Date received: 11 October 1973.introduced during quiet respiration and advanced superior-ly and medially towards the twelfth dorsal vertebral bodyalong the long axis of the liver. The needle was advancedinch-wise for a distance of approximately 12 cm by holdingit near the skin and taking care to avoid bending.Penetration of a biliary duct was assessed, as advocatedby Amer et al.,3 by connecting the needle to a standarddrip extension tube and injecting a small volume of sodiumdiatrizoate 45°~ (Hypaque; Winthrop) while slowly with-drawing. If no duct was entered the injection was stoppedapproximately 2 cm from the liver edge to prevent refluxof contrast into the peritoneal cavity. The needle was re-introduced through the same skin puncture and directedin slightly more posteriorly.On entering the duct system, injection of contrast wascontinued until the biliary tree was adequately filled. Thisrequired up to 80 ml sodium diatrizoate in some cases andwas assisted by taping the cannula in position and turningthe patient into a steep left oblique position while moni-toring the injection. The true site of obstruction was veri-fied by spot films taken in optimum positions which fre-quently included erect views.Where the punctures were successful the ducts' wereinvariably entered during the first two attempts out of amaximum of four.Fig. 1. Carcinoma of the bead of the pancreaswith occlusion of the distal common and cysticbile ducts and gross dilatation of the intrahepaticbiliary tree.L638 S.-A. MEDTESE TYDSKRTF 30 Maart 1974TABLE I. DIAGNOSES BY TRANSHEPATIC CHOLANGIO-GRAM IN 46 CASES (34 SUCCESSFUL PROCEDURES)Fig. 3. Cholangiocarcinoma main hepatic ducts (blackarrow) with moderate intrahepatic biliary dilatation withincomplete obstruction and filling of the distal commonbile duct and gall bladder. The lymphatics draining toglands in the porta hepatis have filled from interstitialinjection (white arrow).Fig. 4. Common bile duct calculus with a convexity atthe site of obstruc!ion (arrow).17636212No.RESULTSThe diagnoses proved at laparotomy in 46 cases are shownin Table I and several examples are demonstratd in FigsI - 5.Carcinoma head of pancreasCommon duct calculi ...Previous biliary surgeryCholangiocarcinomaGall bladder carcinomaUnsuccessfulFig. 2. Carcinoma common hepatic bile duct (low lesion)with gross intra- and extrahepatic biliary dilatation. Thelesion is proximal to the cystic duct origin but the site ofobstruction has a similar appearance to that in Fig. 1.Of the 39 cases with surgically correctable jaundice, thedilated biliary tree was successfully punctured in 34 (85°~).Of the remaining 5 cases, 3 were true failed punctureswhile the remaining 2 had small-calibre ducts due tocholangitis with associated calculi. These 2 cases weretherefore regarded as false negatives.The cause of jaundice in the 7 remaining true negativecases with non-surgical jaundice is shown in Table H.usinesst:'estCephradineReg. Nos. D/20.1.1/251, 252, 253,254,E/20.1.1/128, 136, 137Eskacef**"The bronchitis business had been biotic, for potentially dangerousgood to Haemophilus Ine. But soon after infections. In children and adults.I'd infested in a young boy's chest, profits Respiratory, gastro-intestinal, genito-tumbled. Some bright young doctor urinary and skin/soft tissue infections-prescribed 'Eskacef - 250mg orally every they all need 'Eskacef.6 hours - and that was the end of me. The sooner the better antibiotic.That doctor made a real killing ..." With the added plusses of being onlyS K& F's broad-spectrum 'Eskacef. 6% protein-bound and noThe right-first-time cephalosporin anti- reports of nephro-toxicity.SKQceThe sooner the better antibiotic.For respiratory and other infections.Smith Kline & French Laboratories. Division of Smith Kline & French (Pty) Ltd., Isando Road, Isando, Transvaal.*Regd. Trade Mark. ECF:JA14E30 March 1974 S.A. MEDICAL JOURNAL 639• With the exc<!ption of these 2 cases, laparotomv was unnecessary.COMPLICATIONSTABLE 11. DIAGNOSES OF 12 NEGATIVE TRANSHEPATICCHOLANGIOGRAMS IN 46 CASES221oNo.21ooDISCUSSIONTABLE Ill. COMPLICATIONSMajorHaemorrhageSepticaemiaBiliary leakDeathsMinorTransdiaphragmatic punctureTrans-transhepatic puncturePerivascular punctureGall bladder puncturezontal introduction of the needle. Perivascular injection,initially mistaken for duct entry on screening, was plainlyevident on film. Gall bladder puncture did not occur inthis series as the lateral approach was used in all casesrather than the anterior method described by Seldinger:REFERENCESJ. Varela Fuentes. B., Berloni, C. and Polero. J. (1957): Pren. med.argent., 44, 2873.2. Wiechel, K. L. (1964): Acta chir. scand .• suppJ. 330.3. Arner, 0., Hagberg, S. and Seldinger, S. I. (1962): Surgery, 52, 561.4. Seldinger. S. I. (1966): Acta radiol. (Slockh.), suppL 253.5. Hine3, C., Ferranle, W. A., Davis, W. D. and Tutlon, R. A. (1972):Amer. J. Dig. Dis., 17, 868.In a recent review of I 629 cases from the world literatureby Hines et al.; 1204 punctures (74%) were successfuland the incidence of major complications was 5%. Theresults of our series compare favourably with a successfulpuncture rate in the presence of dilated ducts of 85% anda complication rate of 6%.Partial obstruction due to stones or high lesions, suchas cholangiocarcinoma of the main hepatic duct junction,usually resulted in less dilatation of the intrahepatic radi-cles than low obstructions of the common bile duct dueto carcinoma of the head of the pancreas.In most of the positive punctures an accurate assess-ment of the pathological features of the lesion could bemade. Exceptions were carcinoma of the gall bladder andcarcinoma of the distal common hepatic duct, whilre thefeatures were characteristic of extrinsic obstruction andfrequently indistinguishable from a large carcinoma of thehead of the pancreas (Figs 1 and 2). Cholangiocarcinomaof the main hepatic duct junction (Fig. 3) was diagnosedwith confidence and provided invaluable assistance tothe surgeon, as this lesion was frequently too high topalpate at surgery and could easily have been missed. Incases of previous biliary surgery with fibrosis, accurateindication of the site of the stricture and stone formation(Fig. 5) was useful to the surgeon.The results of this study indicate that in cases wherehepatocellular jaundice is the more likely diagnosis a nega-tive puncture has an 80 - 90% probability of being cor-rect. In such cases, provided the patient is closely moni-tored, laparotomy may be deferred.212"25False negatives (ducts dilated)Carcinoma head of pancreas ...Carcinoma gall bladder ...True negatives (ducts not dilated)Calculi with cholangitis ...Secondary hepatic deposits ...Hepatocellular jaundice ...Fig. 5. Cholecystenterostomy with a stone in the righthepatic duct (black arrow) causing recurrent cholangitis.There is drainage into the gall bladder (white arrow).The complications encountered were divided into majorand minor groups and are shown in Table m. Significantbleeding or leakage of bile into the peritoneal cavity wasinfrequent and in most cases the site of the liver puncturecould not even be identified. In one patient with calculisepticaemia occurred owing to the omission of adequatebroad-spectrum antibiotic cover.Minor complications were all of a technical nature andhad no untoward sequelae. Transdiaphragmatic punctureoccurred with excessive diaphragmatic excursion and in-adequate marking of the puncture site. Bending of theneedle occurred when the thrust applied at the hub andnot near the skin directed it superiorly. Trans-transhepaticpuncture through a thin vertical liver occurred with hori-14

Percutaneous transhepatic cholangiography

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Percutaneous transhepatic cholangiography

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