Download PDF
Endoscopy 2001; 33(3): 201-209
DOI: 10.1055/s-2001-12814
Original Article

© Georg Thieme Verlag Stuttgart · New York

A New System for Rapid Large-Caliber Percutaneous Transhepatic Drainage in Patients with Obstructive Jaundice: A Prospective Randomized Trial

E. Frimberger1 , T. Vente1 , S. Wagenpfeil2 , P. Gerein2 , P. Born1 , N. Fritz1 , H.-D. Allescher1 , R. Ott1 , N. Weigert1 , M. Classen1 , T. Rösch1
  • 1 Depts. of Internal Medicine, Technical University of Munich, Germany
  • 2 Institute for Medical Statistics and Epidemiology, Technical University of Munich, Germany
Further Information

Publication History

Publication Date:
31 December 2001 (online)

Also available at
    Permissions and Reprints

Background and Study Aims: Percutaneous access to the biliary tract is an important diagnostic and therapeutic tool in the management of biliary diseases. It is usually chosen when the endoscopic approach via endoscopic retrograde cholangiopancreatography (ERCP) fails, or is not possible. Once established, the percutaneous tract is then used for the treatment of biliary stones and strictures. To establish a percutaneous tract with a caliber large enough for cholangioscopy to be performed, or for a large-bore permanent drainage tube to be inserted, stepwise dilation up to 14 Fr or 16 Fr is usually required. We present here a new method of rapid dilation using specially designed materials, including a stiffenable guide wire and specially adapted bougies.

Patients and Methods: Consecutive patients undergoing percutaneous drainage for biliary diseases were included in this prospective study, over a 19-month period. After establishment of a 10-Fr transpapillary drain, the patients were randomly assigned to either conventional percutaneous transhepatic biliary drainage (PTBD) or stepwise dilation using the new method, aiming at a need for only one further session, using a specially designed stiffenable metal guide wire of 6.6 Fr and plastic bougies. The details of the procedure (duration, materials used, technical ease), initial and later complications, assessment by the patients, and procedural costs were compared between the two groups.

Results: Of the 60 patients included, 29 were randomly assigned to group I (the new method) and 31 to group II (the conventional approach); there were no significant differences between the two groups in terms of clinical data or biliary pathology. The clinical efficacy of PTBD was similar in the two groups, although three patients in group II were switched to the new procedure because of failure of dilation using the conventional approach. The rates of major complications (four of 29 in group I, five of 31 in group II) and patient tolerance were also similar. However, the new procedure led to a significant reduction in the cumulative procedure duration (20.1 minutes vs 30.1 minutes), mean number of sessions (1.1 vs. 1.7), and mean number of hospital days (2.0 vs 5.5), and was therefore also cost-effective, reducing costs from a mean of 5 813 to 2 581 German marks (DM) per patient.

Conclusions: The new system for rapid establishment of large-caliber PTBD offers significant advantages in terms of saving hospital resources while maintaining clinical efficacy.

References

  • 1 Born P, Rösch T, Bruehl K, et al. Long-term effect of endoscopic and percutaneous transhepatic treatment of benign biliary strictures [abstract].  Gastrointest Endosc. 1999;  49 AB 486
    PubMedGoogle Scholar
  • 2 Born P, Rösch T, Bruehl K, et al. Long-term effect of endoscopic and percutaneous transhepatic drainage in patients with advanced Klatskin tumors [abstract].  Gastrointest Endosc. 1999;  49 AB 673
    PubMedGoogle Scholar
  • 3 Takada T, Yasuda H, Hanyu F. The technique and management of percutaneous transhepatic cholangial drainage for treating obstructive jaundice.  Hepatogastroenterology. 1995;  42 317-322
    PubMedGoogle Scholar
  • 4 Molnar W, Stockum A E. Relief of obstructive jaundice through percutaneous transhepatic catheter - a new therapeutic method.  AJR Am J Roentgenol. 1974;  122 356-367
    PubMedGoogle Scholar
  • 5 Nimura Y, Kamiya J. Cholangioscopy.  Endoscopy. 1998;  30 182-188
    Google Scholar
  • 6 Yee A CN, Ho C S. Percutaneous transhepatic biliary drainage: a review.  Crit Rev Diagn Imaging. 1990;  30 247-279
    PubMedGoogle Scholar
  • 7 Frimberger E, Rösch T, Zillinger C, et al. The force exerted on angulations: an important factor during guide wire and stent positioning through curved strictures [abstract].  Gastrointest Endosc. 1999;  49 AB 278
    PubMedGoogle Scholar
  • 8 Pry R, Miles S G, Hawkins I F, et al. Guide-wire reinforcement and lengthening with coaxial locking guide wires: the crimping technique.  Radiology. 1990;  174 268-269
    PubMedGoogle Scholar
  • 9 Cope C. Stiff fine-needle guide wire for catheterization and drainage.  Radiology. 1983;  147 264
    PubMedGoogle Scholar
  • 10 Clements W DB, Diamond T, McCrory D C, Rowlands B J. Biliary drainage in obstructive jaundice: experimental and clinical aspects.  Br J Surg. 1993;  80 834-842
    PubMedGoogle Scholar
  • 11 Harbin W P, Mueller P R, Ferrucci J T Jr. Transhepatic cholangiography: complications and use patterns of the fine-needle technique: a multi-institutional survey.  Radiology. 1980;  135 15-22
    Google Scholar
  • 12 Nilsson U, Evander A, Ihse I, et al. Percutaneous transhepatic cholangiography and drainage.  Acta Radiol Diagn. 1983;  24 433-439
    PubMedGoogle Scholar
  • 13 Lois J F, Gomes A S, Grace P A, et al. Risks of percutaneous transhepatic drainage in patients with cholangitis.  AJR Am J Roentgenol. 1987;  148 367-371
    PubMedGoogle Scholar
  • 14 Günther R W, Schild H, Thelen M. Percutaneous transhepatic biliary drainage: experience with 311 procedures [review article].  Cardiovasc Intervent Radiol. 1988;  11 65-71
    CrossrefPubMedGoogle Scholar
  • 15 Mueller P R, van Sonnenberg E, Ferrucci J T Jr. Percutaneous biliary drainage: technical and catheter-related problems in 200 procedures.  AJR Am J Roentgenol. 1982;  138 17-23
    CrossrefPubMedGoogle Scholar
  • 16 Burke D R, Lewis C A, Cardella J F, et al. Quality improvement guidelines for percutaneous transhepatic cholangiography and biliary drainage.  J Vasc Interv Radiol. 1997;  8 677-681
    PubMedGoogle Scholar
  • 17 Speer A G, Cotton P B, Russell R C, et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice.  Lancet. 1987;  2 (8550) 57-62
    CrossrefPubMedGoogle Scholar
  • 18 Pellegrini C A, Thomas M J, Way L W. Recurrent biliary stricture.  Am J Surg. 1984;  147 175-180
    CrossrefPubMedGoogle Scholar
  • 19 Huibregtse K, Katon R M, Tytgat G NJ. Endoscopic treatment of postoperative biliary strictures.  Endoscopy. 1986;  18 133-137
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Krömer M U, Maier M, Benz C A, et al. Gallengangsstenosen und -lecks nach Cholecystektomie: Endoskopische Diagnostik, Therapie und Behandlungserfolg.  Z Gastroenterol. 1996;  34 167-172
    PubMedGoogle Scholar
  • 21 Tocchi A, Costa G, Lepre L ,. et al . The long-term outcome of hepaticojejunostomy in the treatment of benign bile duct strictures.  Ann Surg. 1996;  224 162-167
    CrossrefPubMedGoogle Scholar
  • 22 Csendes A, Diaz C, Burdiles P, et al. Indications and results of hepaticojejunostomy in benign strictures of the biliary tract.  Hepatogastroenterology. 1992;  39 333-336
    PubMedGoogle Scholar
  • 23 Moreaux J. Traditional surgical management of common bile duct stones: a prospective study during a 20-year experience.  Am J Surg. 1995;169 220-226
    PubMedGoogle Scholar
  • 24 Larraz-Mora E, Mayol J, Martinez-Sarmiento J, et al. Open biliary tract surgery: multivariate analysis of factors affecting mortality.  Dig Surg. 1999;  16 204-208
    CrossrefPubMedGoogle Scholar
  • 25 Csendes A, Burdiles P, Diaz J C. Present role of classic open choledochostomy in the surgical treatment of patients with common bile duct stones.  World J Surg. 1998;  22 1167-1170
    CrossrefPubMedGoogle Scholar
  • 26 Davids P H, Groen A K, Rauws E A, et al. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction.  Lancet. 1992;  340 1488-1492
    CrossrefPubMedGoogle Scholar
  • 27 Knyrim K, Wagner H J, Pausch J, Vakil N. A prospective, controlled, randomized trial of expandable metal stents in malignant biliary obstruction: final report [abstract].  Gastrointest Endosc. 1993;  39 A321
    PubMedGoogle Scholar
  • 28 Lammer J, Hausegger K A, Fluckiger F, et al. Common bile duct obstruction due to malignancy: treatment with plastic versus metal stents.  Radiology. 1996;  20 167-172
    PubMedGoogle Scholar
  • 29 Prat F, Chapat O, Ducot B, et al. A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct.  Gastrointest Endosc. 1998;  47 1-7
    CrossrefPubMedGoogle Scholar
  • 30 Carr-Locke D L, Ball T J, Connors P J, et al. Multicenter, randomized trial of Wallstent biliary endoprostheses versus plastic stents [abstract].  Gastrointest Endosc. 1993;  39 A310
    PubMedGoogle Scholar
  • 31 Roesch T, Schinner S, Schmitt W, et al. Comparison of three different stents (plastic and metal) for malignant biliary obstruction [abstract; authors “Rosenberg PM et al.” incorrectly cited in published abstract].  Gastrointest Endosc. 1999;  49 AB236
    PubMedGoogle Scholar
  • 32 Wagner H J, Knyrim K, Vakil N, Klose K J. Plastic endoprostheses versus metal stents in the palliative treatment of malignant hilar biliary obstruction: a prospective and randomized trial.  Endoscopy. 1993;  25 213-218
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 Stage J G, Moesgaard F, Gronvall S, et al. Percutaneous transhepatic cholelithotripsy for difficult common bile duct stones.  Endoscopy. 1998;  30 289-292
    PubMedGoogle Scholar
  • 34 Lee M J, Mueller P R, Saini S, et al. Percutaneous dilatation of benign biliary strictures: single-session therapy with general anesthesia.  AJR Am J Roentgenol. 1991;  157 1263-1266
    PubMedGoogle Scholar
  • 35 Chen M F, Jan Y Y. Percutaneous transhepatic cholangioscopic lithotripsy.  Br J Surg. 1990;  77 530-532
    PubMedGoogle Scholar
  • 36 Akiyama H, Okazaki T, Takashima I, et al. Percutaneous treatment for biliary diseases.  Radiology. 1990;  176 25-30
    PubMedGoogle Scholar
  • 37 Flowers B F, Saslawsky M J, Mathes G L, Tonkin A K. Use of the pulsed dye laser and ultrasonic lithotriptor for removal of multiple intrahepatic gallstones.  Surgery. 1990;  170 443-444
    PubMedGoogle Scholar
  • 38 Hwang M H, Mo L R, Yang J C, Lin C. Percutaneous transhepatic cholangioscopic ultrasonic lithotripsy (PTCS-USL) in the treatment of retained or recurrent intrahepatic stones.  Gastrointest Endosc. 1987;  33 303-306
    PubMedGoogle Scholar

T. Rösch, M.D.

Dept. of Internal Medicine II
Klinikum rechts der Isar
Technical University of Munich

Ismaningerstrasse 22
81675 München
Germany


Fax: Fax:+ 49-89-4140-4872

Email: E-mail:Thomas.Roesch@lrz.tu-muenchen.de

      >