treatment of malignant obstruction adjunct to surgery treatment of cbd calculi treatment of...
TRANSCRIPT
PERCUTANEOUS TRANSHEPATICCHOLANGIOGRAPHY ANDBILIARY INTERVENTION
Indications
Treatment of malignant obstruction Adjunct to surgery Treatment of CBD calculi Treatment of benign strictures Diagnostic? Failed ERCP
Patient selection
WHO performance status Imaging Clinician/MDT discussion Coagulation status Ascites
WHO performance status
0 – 2. In bed less than 50% of time BSIR Audit report 2009, 19.8% in hospital
mortality 15.6% in hospital mortality for benign
disease Audit of my procedures, 18% 30 day
mortality Patients with lower WHO performance
status do better
Imaging
Ultrasound. Confirm biliary obstruction, mass, metastatic disease, calculi
CT. Confirm level of obstruction, mass, metastatic disease
MRI/MRCP. Complex biliary strictures, CBD calculi, liver metastases
ERCP. May have failed
Clinician/MDT discussion
Malignant or benign disease Gastroenterologists Surgeons Radiologists Other Healthcare Workers
Malignant Disease
Surgical. ERCP and plastic stent or PTC and Internal/External biliary drainage
Palliative. ERCP or PTC and metallic Stent
Benign Disease
ERCP treatment of choice PTC and internal/external drain or plastic
stent. May enable successful ERCP later
Coagulation status
INR < 1.4. Consider vitamin K, FFP and also Beriplex/Octaplex. Contain prothrombin complex concentrate. Factors II, VII, IX and X as well as Proteins C and S
Platelets > 100,000. If less, consider platelet transfusion
Consent
WHO performance status Check coagulation Explain procedure at least 1 day before Risks. Bleeding, bile leak, infection,
pneumothorax and failure
Anaesthetic
Anaesthetist GA Discuss need for airway protection Use LA When applying for consultant post ask
what access you may have to anaesthetics
Antibiotics
At start of procedure Gentamicin 240 mg IV Metronidazole 500 mg IV Discuss with Microbiology
Equipment
Use what works best for you Chiba needle 22 gauge Trochar needle 18 gauge NEF set Stiff Terumo wire Amplatz wire Catheters. BMC and straight Self expanding stent Internal/External drains 8.5/10.5F. Discuss
with your surgeon
Approach/Technique 1
Ascites present? Drain first Ultrasound? Right lobe. Mid axillary line. Aim for xyphisternum. Left lobe. Locate with U/S and usually aim for
segment III. Very gently inject 1/3 strength contrast (100) as
needle is withdrawn Duct entered when contrast flows away from
needle and persists Duct not entered. Change angle and try not to exit
liver capsule Duct normally anterior to portal vein
Approach/Technique 2
Pre-surgery for cholangiocarcinoma. Discuss lobe to drain. Usually the lobe being preserved.
Pre-surgery for pancreatic cancer. Right lobe puncture.
Palliative. Drain right, left or both? 1. Chiba needle to opacify ducts then choose
duct for trochar puncture and wire etc. 2. NEF set. Single puncture then wire, dilator
and access sheath Consider bile for cytology if no diagnosis
Approach/Technique 3
Stiff Terumo to cross lesion. Use pin vice for torque
Straight catheter Amplatz wire Dilator Stent/Drain 1 or 2 stage procedure? Temporary drain following stent? Plug track? Coils, gelfoam etc. Technical success >95% (BSIR audit)
Approach/Technique 4
Unable to cross stricture, establish external drainage (8.5F internal/external drain). Further attempt after decompression usually successful.
Care with drainage bag essential. Internal external drainage, try not to use
bag and bung catheter.
BSIR Audit. Mortality & Complications (reported)
In hospital mortality 19.8%. Death or major complication 21.2% overall, 18.3%
benign, 21.7% malignant. Major complications in 7.9%, haemorrhage 3.5%,
renal failure 1.8% and sepsis 1.6%. Minor complications in 26.0%, pain 14.3%, sepsis
7.7% and haemorrhage 4.5%. Association with ascites, elevated INR and low
platelets. 1 year survival <20% for malignant disease. Drainage more effective if stents placed across
ampulla
BSIR recommendations
1. Further audit of this cohort is required to determine cause of death and to demonstrate whether or not there are significant associated risk factors.
2. Given the high mortality in this group of patients further data collection will be required. Significant improvements in data completeness are required. Data submission remains voluntary, but NHS services should consider how they can make resources available to support data collection for individual operators
Case 1
86 yr female presented with sepsis and subsequent jaundice
Arteriopath but otherwise reasonably fit CT
Case 1
Abscess right lobe liver drained Antibiotics MDT discussion, for palliation ERCP, failed to stent due to large
duodenal diverticulum PTC
Case 2
69 yr male with obstructive jaundice CT, operable mass in head of pancreas MDT discussion Surgical candidate ERCP to place plastic stent failed PTC
Case 3
75 yr female with obstructive jaundice CT, large central liver mass, likely
cholangiocarcinoma. Further deposit in segment II
MDT discussion, not operable, palliative PTC and stent left lobe
Case 4
71 yr male Metastatic colorectal cancer Multiple liver resections Jaundice with recurrent liver and
peritoneal tumour Considering further chemotherapy CT Small residual liver with mild duct
dilatation ERCP failed
Case 5
59 yr female with inoperable cholangiocarcinoma
Previous ERCPs with plastic and finally recently metal stent into left lobe
Recurrent jaundice ?percutaneous options
Take Home Points
Careful patient selection after MDT discussion
“Appropriate” Anaesthesia Try not to use external drainage bags