Biliary Interventions

Biliary Anatomy & Access - Gut's Golden Pipes

• Intrahepatic Ducts: Right & Left hepatic ducts converge to form Common Hepatic Duct (CHD).
• Extrahepatic Ducts:
  • Gallbladder → Cystic Duct.
  • Cystic Duct + CHD → Common Bile Duct (CBD).
  • CBD + Pancreatic Duct → Ampulla of Vater → Duodenum.
• Percutaneous Access:
  • Right-sided: Mid-axillary line, transhepatic, commonest.
  • Left-sided: Subxiphoid, for isolated left ductal system.

⭐ The most common percutaneous biliary access is via a right mid-axillary transhepatic approach, targeting a peripheral right hepatic duct (segments 6 or 7).

Indications & Contraindications - Green Light, Red Light

⭐ PTBD is often preferred for high biliary obstructions (e.g., Klatskin tumors), while ERCP is typically first-line for distal obstructions.

Biliary Procedures - The IR Plumber's Toolkit

• Percutaneous Transhepatic Biliary Drainage (PTBD): Decompresses obstructed biliary system.

  • Access: Typically Rt. mid-axillary, US/fluoroscopy guided.
  • Drainage Types: Internal-external (across stricture) or purely external.
  • Key Uses: Malignant/benign obstructive jaundice, acute cholangitis, pre-operative decompression.

• Biliary Stenting: Maintains biliary duct patency post-dilatation or for palliation.

  • Plastic Stents: Temporary, smaller diameter; for benign strictures, require frequent exchanges.
  • Self-Expanding Metallic Stents (SEMS): Larger diameter, longer patency; for malignant obstructions.
    • Covered SEMS: Prevent tumour ingrowth, potentially removable; higher migration risk.
    • Uncovered SEMS: Embed into wall, less migration; risk of tumour ingrowth/epithelial hyperplasia causing occlusion.

• Percutaneous Cholecystostomy (PC): Drains gallbladder in high-risk patients.

  • Main Indication: Acute cholecystitis when surgery is contraindicated.
  • Technique: US-guided transhepatic or transperitoneal catheter placement.

• Other Interventions:

  • Biliary Dilatation: Balloon catheters for benign/malignant strictures.
  • Stone Extraction: Using baskets (e.g., Dormia) or balloons, often via T-tube tract or PTBD access.

⭐ In malignant biliary obstruction, SEMS (Self-Expanding Metallic Stents) offer superior long-term patency compared to plastic stents.

Complications & Management - Navigating Rough Waters

• Hemorrhage:
  • Arterial: Angioembolization.
  • Venous: Pressure, often self-limiting.
• Sepsis/Cholangitis:
  • IV antibiotics.
  • Ensure/optimize biliary drainage.

  ⭐ Acute cholangitis (Charcot's triad: fever, jaundice, RUQ pain) is a critical risk; manage with IV antibiotics & urgent biliary drainage.

• Bile Leak/Biloma:
  • Percutaneous drainage of collection.
  • Consider stent adjustment/new placement.
• Pancreatitis:
  • Usually mild; supportive care (NPO, analgesia).
• Pneumothorax (supracostal access):
  • Observe if small; chest tube if symptomatic/large.
• Catheter Issues (Dislodgement/Occlusion):
  • Fluoroscopic repositioning.
  • Flush; if fails, exchange catheter.

High‑Yield Points - ⚡ Biggest Takeaways

• PTBD is vital for biliary obstruction if ERCP fails or is contraindicated.
• Right-sided PTBD access is standard, targeting peripheral ducts to minimize risks.
• Key PTBD complications: hemobilia, sepsis, bile leak, pneumothorax.
• Metallic stents offer superior long-term patency over plastic stents in malignant strictures.
• Percutaneous cholecystostomy drains acute cholecystitis in surgically high-risk patients.
• Rendezvous technique combines percutaneous and endoscopic routes for challenging biliary access.