PERCUTANEOUS ULTRASOUND GUIDED BILIARY DRAINAGE. FACTORS THAT AFFECT PERFORMANCE AND COMPLICATIONS RATE

Purpose: To study the factors that affect the feasibility and safety of ultrasound guided percutaneous biliary drainage (PBD) in the treatment of malignant obstructive jandice.

Methods and Materials: Between 2000–2004 we performed US guided PBD in 40 patients (23 males, 17 females). The indications for PBD were: hilar obstructions (20 pts), middle common bile duct obstructions (12 cases) and distal obstructions caused by pancreatic tumors (8 cases) in which endoscopic drainage was not possible. We performed right-sided PBD in 15 cases and left-sided PBD in 25 cases using 5–8 F “pigtail“ catheters, which were inserted into the branch ducts using the “Seldinger technique“. The puncture of intrahepatic bile ducts was done with an 18F needle using the freehand technique in 60% and with attachable needle guides in 40% of cases. To avoid the puncture of vessels around the bile ducts, PBD was performed with color Doppler guidance in 75% of cases. Later on, an endoprosthesis was endoscopically placed using the “rendes-vous“ procedure in 4 cases (3 hilar and 2 distal obstructions). The contraindications for PBD were abnormal bleeding parameters and ascites. We have studied the influence of the following parameters on the success and complication rates: degree of bile ducts dilatations, the approaches to bile ducts (left or right sided), diameter of the catheter, guidewire's type and operator experience.

Results: Percutaneous echoguided biliary drainage was successful in 85% (34/40) of cases after the first attempt and in 92,5% (37/40) after the second. The overall complication rate was 15% (6/40). There were 3 minor (7,5%) (hemobilia 2 pts, intraperitoneal bleeding) and 3 major complications (bile leakage with peritonitis 2 pts, and hemoperitoneum 1 pt.) which required surgery. During the procedure we have encountered technical problems related to catheter insertion and guidewire insertion or removal in 12 cases (30%). The problems could be overcomed in 50% of cases by changing the guidewires or using a smaller catheter. The following parameters were associated with PBD failure or technical difficulties: less experienced operator, minimally dilated bile ducts, normal sized left lobe in case of left sided PBD, use of large catheters and flexible (soft)guidewires.

Conclusions: Ultrasound guided percutaneous biliary drainage is a successful and safe method for biliary decompression. The success and complications rates are related to some anatomical details, material used and operator experience.