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Introduction | When Bile Stops Fowing: The Critical Role of IR
Introduction | When Bile Stops Fowing: The Critical Role of IR
2018AVIRbiliarycenterchapterdisclosuresfull videomedical
The Gallbladder & Bile | When Bile Stops Fowing: The Critical Role of IR
The Gallbladder & Bile | When Bile Stops Fowing: The Critical Role of IR
2018AVIRbilebiliarychaptercommondistalductductsduodenumfull videogallbladderhepaticNonesphincter
Why IR & When is it Indicated? | When Bile Stops Fowing: The Critical Role of IR
Why IR & When is it Indicated? | When Bile Stops Fowing: The Critical Role of IR
2018anesthesiaAVIRbiliarycannulationcardiovascularchaptercomorbiditiesductendoscopicendoscopyercpfull videogastricinterventionalinvasivemalignantminimallysurgeryunfavorable
Percutaneous Cholecystostomy | When Bile Stops Fowing: The Critical Role of IR
Percutaneous Cholecystostomy | When Bile Stops Fowing: The Critical Role of IR
2018accountsacuteanesthesiaAVIRchaptercholecystectomycholecystostomycomorbiditiesfull videogallbladderlaparoscopicpercutaneousstones
Percutaneous Cholecystostomy: Imaging | When Bile Stops Fowing: The Critical Role of IR
Percutaneous Cholecystostomy: Imaging | When Bile Stops Fowing: The Critical Role of IR
2018acuteAVIRbilechaptercholecystitisductfluidfull videogallbladdergallstonehemorrhagichypoechoicultrasound
Percutaneous Cholecystostomy: Procedure | When Bile Stops Fowing: The Critical Role of IR
Percutaneous Cholecystostomy: Procedure | When Bile Stops Fowing: The Critical Role of IR
2018AVIRbilechaptercholangiogramdetermineductfull videoliverneedleopacifyperitoneumpigtailseldingertranshepatictube
Cholecystoscopy & Cholecystolithotripsy | When Bile Stops Fowing: The Critical Role of IR
Cholecystoscopy & Cholecystolithotripsy | When Bile Stops Fowing: The Critical Role of IR
2018AVIRbasicallybiliarychapterdrainductfull videogallbladderlaparoscopicminimallypatienttractwire
Biliary Obstruction | When Bile Stops Fowing: The Critical Role of IR
Biliary Obstruction | When Bile Stops Fowing: The Critical Role of IR
2018AVIRbilebiliarychaptercolordilatedextrinsicfull videoiatrogenicmalignantmrcppancreatitisstentstricture
Biliary Obstruction: Transhepatic Approach | When Bile Stops Fowing: The Critical Role of IR
Biliary Obstruction: Transhepatic Approach | When Bile Stops Fowing: The Critical Role of IR
2018AVIRbilebiliarybilirubinchapterfull videogallbladderInterventionspercutaneousportalstasistranshepatic
Biliary Obstruction: Subcostal/Intercostal/Ductal Approach | When Bile Stops Fowing: The Critical Role of IR
Biliary Obstruction: Subcostal/Intercostal/Ductal Approach | When Bile Stops Fowing: The Critical Role of IR
2018accessAVIRbilebiliarycatheterchaptercolordilatordrainductductalductsduodenumentryfull videogainhematomaneedleopacifypigtailpleuralsubcostalwire
Biliary Obstruction: Subcostal VS Ductal Approach | When Bile Stops Fowing: The Critical Role of IR
Biliary Obstruction: Subcostal VS Ductal Approach | When Bile Stops Fowing: The Critical Role of IR
2018ascitesAVIRchapterdilateddisadvantagesductexposurefluoroscopicfull videointercostalpericatheter
Conversion of an External Biliary Drain to Internal/External Biliary Drain | When Bile Stops Fowing: The Critical Role of IR
Conversion of an External Biliary Drain to Internal/External Biliary Drain | When Bile Stops Fowing: The Critical Role of IR
2018AVIRbilebiliarycatheterchaptercholangioplastydraindrainageexternalformedfull videohydrophilicpigtailproximal
Cholangioplasty of Biliary Stricture | When Bile Stops Fowing: The Critical Role of IR
Cholangioplasty of Biliary Stricture | When Bile Stops Fowing: The Critical Role of IR
2018antegradeAVIRbiliarychaptercholangioplastycystadenomafull videohepatectomyhydrophiliciatrogenicpruritisstricture
Internalization of Biliary Stent | When Bile Stops Fowing: The Critical Role of IR
Internalization of Biliary Stent | When Bile Stops Fowing: The Critical Role of IR
2018angiographicantegradeAVIRbilebiliarychapterdrainfull videopigtailstentviabil
CBD Stent Occlusion | When Bile Stops Fowing: The Critical Role of IR
CBD Stent Occlusion | When Bile Stops Fowing: The Critical Role of IR
2018antegradeAVIRchaptercholangiogramdistalductfull videolumenmalignancymalignantoccludedovergrowthstentstentsstrictureunresectable
Brush Biopsy | When Bile Stops Fowing: The Critical Role of IR
Brush Biopsy | When Bile Stops Fowing: The Critical Role of IR
2018AVIRbiliarybiopsybrushchapterforcepsfull videoobstructionproximaltransluminal
Case: Brush Biopsy of Suspected Malignant Stent Invasion | When Bile Stops Fowing: The Critical Role of IR
Case: Brush Biopsy of Suspected Malignant Stent Invasion | When Bile Stops Fowing: The Critical Role of IR
2018AVIRbiopsybrushchapterdilatedfull videohepaticinfiltratingmalignancy
Benign Disease: Percutaneous Papillotomy | When Bile Stops Fowing: The Critical Role of IR
Benign Disease: Percutaneous Papillotomy | When Bile Stops Fowing: The Critical Role of IR
2018AVIRballoonbenignbilebiliarychaptercholangiogramductduodenumendoscopicercpfillingfull videoopacificationpapillapercutaneoussphincterstonestranshepatic
Benign Disease: Rendevous Procedure | When Bile Stops Fowing: The Critical Role of IR
Benign Disease: Rendevous Procedure | When Bile Stops Fowing: The Critical Role of IR
2018antegradeAVIRbilebiliarychapterductercpexchangefull videostenttranshepatic
Transcript

- Good morning, everyone. So we're gonna go ahead and get started. So our first speaker is Dr. Joseph DeMarco. Dr. DeMarco received his DO degree at the New York College of Osteopathic Medicine. His residency was obtained through Meadowlands Hospital Medical Center

in Atlantic Health System. He's currently active in his fellowship at Albany Medical Center in New York. Dr. DeMarco also moonlights as a radiology attending for community care physicians and has served as a content specialist editor

for It's About Time Publishing based in Armonk, New York. In 2017, he was the recipient of the RSNA, Roentgen Resident and Fellow Research Award. And in 2015, was awarded the SIR National Case Competition Winner at the annual meeting in Atlanta.

Please help me in welcoming Dr. DeMarco. (clapping) Thank you. - Good morning, everyone. Thanks for coming so early in the morning. So, my topic is biliary interventions.

So I thought we'd spice it up a little bit and call it When Bile Stops Flowing: The Critical Role of IR No disclosures yet, a couple thank-you's to some of my mentors.

There is no transcript for this clip.

So where does IR really come in? So surgery and ERCP and endoscopy are really the mainstays of treatment for both benign and malignant pancreatic biliary disease. But interventional radiology plays a role

in providing minimally invasive solutions to biliary problems that maybe surgery or endoscopy can't solve. So here are some of these situations. We have high-risk surgical candidates that aren't able to undergo surgery

or anesthesia sedation who may have cardiovascular comorbidities or severe sepsis. They have unfavorable anatomy for ERCP access into the biliary system, and this could be due to prior gastric bypass or placement of stents.

There could be malignant disease that precludes the ERCP cannulation of the duct distally. And you can have a high biliary obstruction, kind of high up into that biliary system, which is unamenable to endoscopic intervention. And then there could be this cooperative approaches

between GI and IR, so-called rendezvous approach, which we'll get into. So here are some of the minimally invasive options that IR provides, and we're gonna go through each of these.

So first is probably one of the more basic procedures that we do

is percutaneous cholecystostomy or gallbladder drain. And what are the indications for this? Usually, it's in a situation of acute cholecystitis, which is acute inflammation of the gallbladder. It comes in two varieties, one being calculous and one being acalculous.

So if there're stones, it's calculous, and these stones block the gallbladder neck and cystic duct, and it's usually, it accounts for about 90% to 95% of the situations. There can also be where there's no stones and are maybe sludge and general inflammation.

And these usually happens in critically ill and elderly patients. And overall, this whole picture accounts for about 20 million people in the US every year. So like I mentioned a little earlier, laparoscopic cholecystectomy,

which general anesthesia may not be possible, due to comorbidities or instability. And we can provide a gallbladder drain in order to either temporize the situation until cholecystectomy is possible or have a definitive treatment.

So here's some of the imaging characteristics of acute cholecystitis. So here's a CT which shows gallstones as well as gallbladder wall thickening and pericholecystic fluid, a classic situation for acute cholecystitis.

Here's the ultrasound equivalent with gallstones showing shadowing. There's actually a gallstone here in the common bile duct or gallbladder neck. And you can have pericholecystic fluid kind of this rim of hypoechoic fluid around.

Here's a situation where there aren't any gallstones, and this patient actually has acalculous cholecystitis with free fluid on ultrasound and actually had hemorrhagic cholecystitis. And you can see that high-density material within the gallbladder here.

So how's this performed? There's a little diagram here. Basically, we have to get access into the gallbladder. And the way we do that is either through a transhepatic approach through the liver itself, or we can go subcostal,

directly into the fundus of the gallbladder. We like to go through a little bit of liver to provide some stability. And basically, a needle goes into there. We use Seldinger technique where we coil a wire within there.

And then dilate the track and lead the pigtail drain. So here's a real-life example here of this transhepatic approach. Here's our needle under ultrasound guidance going into the gallbladder. We opacify the gallbladder with some contrast

and confirm that our tube is in proper place. So the tube's in, now what? Do we just live it in place? In some situations, that's what's indicated. Other situations, they may come back for a change. But the tube actually has to remain in place

for about four to six weeks in order to allow that track to mature. If it doesn't mature, then you can have leakage of bile into the peritoneum called, cause bile peritonitis. So we can bring them back and perform a cholangiogram which is basically an injection

through the existing catheter. And that's done, one, to determine if that cystic duct is patent. If it is patent, then the inciting event is over, and the tube can be removed. And we can also determine if that

transhepatic tract is mature before we remove the tube.

So there's some interesting new frontiers that actually are being presented here at SIR this year called cholecystoscopy and cholecystolithotripsy. So we, as IRs, may now be able to treat these patients with a minimally invasive solution.

And allow the patient to be tube-free. So the general process is basically we place a gallbladder drain through the approaches that we talked about. They return in about three weeks, allowing for that tract to mature.

They then place a stiff wire through that existing drain, exchange the drain for a nine-French sheath, place a safety wire just to maintain access. They dilate the tract up with a eight-millimeter balloon. And place a 24-French cannula. And basically, doing a laparoscopic procedure

with a 22.5 French rigid endoscope. We're basically blasting away all those stones into a bag, using either graspers, homing lasers, and then leave the patient with an internal-external transcystic biliary duct and a cholecystostomy.

And they return and basically in about four weeks after that, they're tube-free. So kind of a cool, new advancement.

So now we'll just talk about other kinds of biliary obstructions. So like we mentioned, bile is produced by the liver,

can't drain into the small bowel due to benign or malignant disease. And typically, these patients present with jaundice or the yellowing of the skin, could be painless or painful. They have itchy skin or they may even have

blood in their urine. And the causes are multiple, whether it be extrinsic compression from something like a pancreatic mass, malignant stricture due to intrinsic cancer within the gallbladder,

uh, within the ducts, such as cholangiocarcinoma. They could have gallstones within the common bile duct. They can have chronic pancreatitis that causes stricturing of those ducts. And then there could be iatrogenic issues where a prior stent was placed

that has migrated or occluded. There could be improper placement of one of these stents. Or you can have surgical issues causing stricture. So here's some imaging, um, to show what biliary obstruction looks like.

So we have an ultrasound here which shows that there's these dilated ducts right here. The important part is putting color flow on which delineates it from a blood vessel. Here's a CT correlate of these dilated ducts, multiple here.

And they course directly next to the hepatic veins. And here's an MRCP where it's a 3D rendering basically after MR, which shows fluid sensitives, It's basically a fluid-sensitive sequence, and it shows this dilation of the biliary ducts.

So, a transhepatic biliary approach

is indicated for a few reasons. One being drainage and solution to the problem. So patients may have these elevated bilirubin levels. They may have a need for initiating chemotherapy for secondary malignancy. So you wanna bring those bilirubin levels down.

They could have cholangitis, so an infection of the gallbladder cause of all the stasis of all the ducts, or they could have a bile leak. And it's also a portal for providing some of these percutaneous interventions that we can provide.

So first, we'll just talk about a right-sided subcostal or intercostal approach. So, the basic technique is accessing the bile duct from a mid-axillary line approach through the ninth or eleventh interspaces or if possible, going as low as possible

to avoid that pleural reflection. And you're aiming the needle towards the xiphoid process or cardiac apex. Once we're in, then we kinda retract the needle and provide negative pressure till we see that there's bile within the tube.

And then we inject a small amount of contrast to opacify those ducts and assess our entry point. If possible, we use that entry point, if it's amenable. If not, then we re-stick to provide more peripheral access. And you can see here, so this is our initial access to kinda gain an idea of what the bile ducts look like.

We thought it was kind of a tortuous course. Or sometimes it's too central and you don't wanna dilate up too much. You have a risk of hematoma at that point. So we get a secondary access, targeting one of these vessels that is more amenable

and then able to the procedure from there. So once we have that, then, we get a wire and catheter down, pass the stricture, into the duodenum, loop it in the duodenum over a stiff wire then we're able to advance our biliary drain and form the pigtail within the duodenum.

So there's also a left-sided approach, which is also known as the ductal or sub-xiphoid approach. And basically, this uses ultrasound guidance to gain access into the biliary ducts. So you can see here, again, we have these tubular structures without flow based on color imaging.

And we access with a 20 or 22-gauge needle directly into there, do the same basic system as opacifying the system with contrast. And then we can advance a tri-coaxial dilator system, catheter dilator to kinda opacify this, and then wire down into the duodenum

and placement of that internal-external biliary drain with a pigtail formed in the duodenum.

So, you may ask why should we do a left-sided approach or why should we do a right-sided approach? So, left has some advantages. It's relatively easier to perform

cause you're actually visualizing the duct and not having to do this kind of guessing game as in the right. Patient compliance is a little bit better. Patients say it's a little more comfortable for them cause it's not in a intercostal approach.

And it's also preferred when there's ascites present, so you don't have that pericatheter leak. Disadvantages to the left-sided approach is, is more fluoroscopic hand exposure on the operator's part. As far as providing a right-sided approach, more segments are actually covered by the right side,

so if you have a really dilated system, right side might make more sense. There's less hand exposure for the operator. But some disadvantages again are that painful intercostal approach, and it can actually fall out if it's not placed all the way in

because of this respiratory motion, kinda up and down, causes it to pull back.

So we've put in the internal-external biliary drain, why is the patient back? Haven't we solved the problem? Why are they coming back to us?

So we'll talk about each of these. The first is a conversion of an external biliary drain to an internal-external biliary drain. So there may be situations where you can't get through one of these malignant obstructions. You've tried every trick that you know and it's not working.

And the best thing in those situations is to just regroup, and you place that external biliary drain. So you have the pigtail, which is this formed within the most distal point of your bile duct, and that'll provide drainage of all of these bile ducts. And you let the system decompress for a few days or a week,

and then you bring 'em back, and you'll be surprised that after all that, all inflammation has come down a bit, and you're able to get through. So the way we do that is you take that drain off over wire, and we're gonna probe with a catheter

as well as a hydrophilic wire, whether it be an .035 system or .018 system. And you're able to get through that, um, that obstruction. So here's a situation where we, we successfully crossed that obstruction that was there.

We actually like to perform a little cholangioplasty where we inflate a balloon to help our catheter advance over the wire and into the duodenum. And here's an example of one of these internal-external biliary drains. Again, with the pigtail formed in the duodenum.

It has these multiple side holes to allow drainage. But the important part is that you want this proximal marker to be beyond where your entry site was on the initial stick of, into the gallbladder. I'm sorry, into the bile ducts. If not, then you have leakage,

but you wanna cover this whole area so that you allow all the drainage from the bile ducts to go down into the duodenum.

So, we can also do what's called cholangioplasty of a biliary stricture. So here's an example of a 51-year-old male

who had an extended right hepatectomy for a suspected biliary cystadenoma or cystadenocarcinoma. And the patient ended up developing pruritis and elevated liver-function tests. And so we did got access into the biliary tree, and we see that there's this stricture right here.

So this was a iatrogenic surgical stricture. And so we were able to get past with a hydrophilic wire and catheter. We inflated a balloon, this was a six-millimeter high-pressure balloon, across the stricture, prolonged the inflation for two minutes.

And then once we took that down, we take it out over the wire, and we're able to inject them. We can see that we've solved the problem, and now there's antegrade flow through the stricture and into the duodenum.

So we can also internalize two biliary stent

from one of these internal-external drains. And that provides a lot of patient comfort instead of being hooked to a drainage bag continually for the rest of their life. This is a nice option for them. So here's a case example of a 67-year-old male

who had failed ERCP, he had obstructive jaundice secondary to a pancreatic head mass. And we can see that mass right here, and it's causing obstruction right at the common bile duct, distal common bile duct. And this is the angiographic correlate.

So they requested that we place an internal-external drain. So, we realized that this patient, we were able to get through basically through a left biliary access. We placed the marking pigtail catheter. So you could see this is,

each one of these marks is one centimeter, so we're able to estimate once we're through how far, how long our stent should be, and we're able to put in a 10 x 80 covered VIABIL stent which we post dilated with a balloon, and we restored antegrade flow.

And we'd leave a drain in place until we know that that stent remains open. We can cap the drain and allow them to kinda drain antegrade into the bowel. And if they tolerate that, bring it back for, um, an injection cholangiogram.

If it's patent, then remove the drain, they're drain-free.

So, these are great, but sometimes, they can occlude. So here's an example of a 49-year-old female who had a Roux-en-Y bypass, had an unresectable pancreatic malignancy and was previously treated with a common bile duct stent.

And this actually occluded due to malignant overgrowth. I don't know if you can see this, but here's the lumen of the stent, very, very narrow. And then you have all of this overgrowth where it's not opacified. So what can we do? We can realign this with a new stents.

So we ended up placing covered stents through that existing stent. And this was an interesting case in that. So we did that, we've repeated our cholangiogram to make sure that it was open, and we actually saw that there was an additional stricture

probably due to a malignant overgrowth right at the distal aspect in the second and third portion of the duodenum. So we extended that stent even further into the duodenum, beyond that stricturing point, and we see that we restored complete antegrade flow

into the small bowel.

So we can also provide a diagnosis with a biopsy. So, in order to do transluminal biliary biopsy, we can do it one or two ways. Usually, the first way we try is a brush biopsy, and second way would be a forceps biopsy.

And it's important to do this, to get a diagnosis, because one in five patients who have this suspected malignant obstruction are actually misdiagnosed. So this could be really life-changing for these patients. So how do we do it?

We get guide-wire access through the obstruction. We advance a sheath just proximal to that obstruction or just beyond the obstruction. And then we take a brush biopsy device or the forceps to grab larger pieces. With the brush biopsy, we're doing kinda like the spiral

to and fro motion and basically back and forth through the area of obstruction and put that into a fixative. So here's the two different systems that we have. So this is the brush biopsy. Again, a to and from motion for that,

and here are some biopsy forceps.

So two examples for ya. Here's an example of a brush biopsy that we performed. 77-year-old male who had dilated left hepatic ducts. A very irregular kinda appearance to these. So we were concerned that there was an infiltrating process.

And again, had prior Roux-en-Y bypass, which precluded them from getting this through an ERCP. So, we advance our wire beyond that stricture. We put the sheath right up to the area of the stricture. And here's the biopsy brush that we kinda brushed back and forth in order to get a sample.

And that confirmed that he actually had malignancy of cholangiocarcinoma.

So here's an example of forceps biopsy. So again, you're gonna get the sheath down to the level of the obstruction, and this is the, kinda the head of the forceps,

kinda probed right within that region. And then you open up the forceps while provide some forward antegrade pressure. And we're able to take a sample directly of that area of obstruction.

So we can also treat benign biliary disease,

and usually ERCP is kinda the primary treatment, but we can aid when, you know, the anatomy precludes them from doing so or, um, they basically need our help to get through. So, um, benign disease usually is caused by having stones. So one way that we can treat this is

percutaneous papillotomy. So it's an alternative to the endoscopic approach of retrieving these calculi. And basically, the way we do this is we obtain transhepatic access just like we talked about, either right or left-sided biliary approach,

perform an angiogram, and like in this case, see opacification of all the bile ducts, common bile duct, down to the duodenum. But we see that, these filling defects, and these are the gallstones that migrated into the common bile duct

and giving this patient cholangitis. So, we get access beyond those stones into the duodenum and then we get a balloon to dilate the papilla. So basically, right here you see like, this kinda narrowing area, right before it enters into the small bowel,

and you get rid of basically the papilla that is a sphincter basically. Once that's dilated, then we're able to push everything forward, whether that be in this kind of fashion with the Fogarty balloon, down into the duodenum.

And here's the balloon inflated into the duodenum now. Or you can even use a saline to kind of push everything forward. So we repeat the cholangiogram and we see that, now, there's none, none of these filling defects that were there.

So we've successfully relieved the obstruction and pushed those stones into the small bowel, which will then just go away.

And last, we'll just talk about the rendezvous procedure, which I alluded to earlier. And this is collaborative effort really between IR and GI.

And it helps in those cases where they're not able to get access, but they may need some push, ability to come and sweep the whole common bile duct if we're not able to do so. So, we again get transhepatic access,

a biliary catheter is usually placed, and then, once we do our part, we transfer them over to the GI suite, and we're able to exchange that biliary drain for an exchange link guide wire. And then once they do their part in ERCP,

here's the ERCP scope, they're able to snare the end of our wire that we placed and bring it all the way through up their endoscope. So that kind of provides a through-and-through access. And then based on that access, they're able to dilate a Fogarty balloon,

kinda like we did with the papillotomy and sweep the whole duct, free to replace the stent if need be. So this is a nice example where we did so, and we provide antegrade flow through and no more disease within the common bile duct.

And that's it, thank you. (clapping)

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