AJR 2003; 181:717-719
© American Roentgen Ray Society
Single-Wall Puncture: A New Technique for Percutaneous Transhepatic Biliary Drainage
Sang H. Lee1,
Seong T. Hahn1,
Hyung J. Hahn2 and
Kyung J. Cho3
1 Department of Radiology, St. Mary's Hospital, The Catholic University of
Korea, #62, Youido-dong, Yongdungpo-gu, Seoul 150-010, Korea.
2 College of Medicine, Konkuk University, #322, Danwol-dong, Chungju 380-701,
Korea.
3 Department of Radiology, University of Michigan Hospital, 1500 E. Medical
Center Dr., Ann Arbor, MI 48109-0030.
Received January 27, 2003;
accepted after revision March 20, 2003.
Address correspondence to S. T. Hahn
(sthahn{at}cmc.cuk.ac.kr).
Abstract
OBJECTIVE. The purpose of our study is to evaluate the safety and
utility of a new single-wall puncture technique for percutaneous transhepatic
biliary drainage in comparison with the conventional double-wall puncture
technique.
CONCLUSION. Our results suggest that the single-wall puncture
technique is a useful method for percutaneous transhepatic biliary drainage
and may be safer than the conventional double-wall puncture technique.
Introduction
Percutaneous transhepatic biliary drainage has played an important role in
the treatment of obstructive disease of the bile duct
[1,
2]. Typically, more than one
needle puncture is needed for adequate catheter positioning in biliary
drainage. Therefore, percutaneous transhepatic biliary drainage carries the
risk of hemorrhagic complications for many patients. Risk factors for
hemorrhagic complications after percutaneous transhepatic biliary drainage
include puncturing of adjacent vessels and ducts, trauma by tract dilatation,
coagulopathy, and so forth. Many interventional radiologists use the standard
double-wall puncture technique, in which the needle may traverse other ducts
or vessels, even when the target duct is punctured successfully. To reduce the
risk of hemorrhagic complications associated with the double-wall puncture
technique, we tested a new single-wall puncture technique. This new technique
is a method of ductal puncture that could reasonably be expected to reduce the
risk of undesirable vessel puncture by using a forward approach, in comparison
to the pullback approach used with double-wall puncture. The purpose of this
prospective study was to assess the safety and efficiency of the single-wall
puncture technique by comparing several of its parameters with those of its
conventional double-wall counterpart.
Subjects and Methods
Thirty-nine consecutive patients (23 men and 16 women; age range, 40-86
years) with biliary obstruction underwent percutaneous transhepatic biliary
drainage during a recent 11-month period. Patients who had repeated
percutaneous transhepatic biliary drainage during this period were not
included in this study. The underlying causes of disease were
cholangiocarcinoma in 19 patients (49%), pancreas head carcinoma in 17
patients (44%), and stone disease in three patients (8%). All patients were
premedicated with an intramuscular injection of 25 mg of pethidine
hydrochloride (Demerol, Keuk Dong Pharmacy, Inchon, Korea) approximately 30
min before the procedure.
The study patients were randomly classified into two groups by admission
date: those on whom percutaneous transhepatic biliary drainage was performed
with the single-wall puncture technique were admitted during the first 6
months (group A, n = 21), and those on whom percutaneous transhepatic
biliary drainage was performed with the double-wall puncture technique were
admitted during the following 5 months (group B, n = 18).
In group A, we used specially designed devices. A 20- or 21-gauge Chiba
needle 15-cm long (M.I. Tech, Seoul, Korea) was connected to a
Y-adaptor (Boston Scientific, Tullamore, Ireland). A syringe filled
with diluted contrast medium was attached to the side arm of the
Y-adaptor. A 0.018-inch, 60-cm guidewire was inserted into the opened
central lumen of the Chiba needle for immediate access when the needle
punctured the bile duct (Fig.
1). The skin of the right flank was prepared and 2% lidocaine was
injected with a 22-gauge needle. Single-wall puncture began with the
advancement of the needle through the skin to the liver. Subsequently, diluted
contrast medium was injected through the side arm of the Y-adaptor
while the needle was slowly being advanced into the liver parenchyma under
fluoroscopic guidance (Figs.
2A, and
2B). After a duct was entered,
a cholangiogram was obtained with further injection of contrast medium. After
injection, the guidewire was inserted toward the liver hilum and into the
common bile duct. Radiographs were obtained with the patient in a supine
position to measure the depth of the needle tract. The needle was then
removed, and the thin-walled sheath was inserted over the guidewire. The wire
was replaced by a 0.035-inch Radifocus guidewire (Terumo Medical, Tokyo,
Japan). Finally, along the guidewire, a biliary drainage catheter was placed
with its tip in the biliary tree or duodenal loop. If a bile duct was not
entered or if peripheral vessels were punctured during the first trial, the
needle was withdrawn to the liver periphery and redirected, and the trial was
repeated. If the punctured duct was occluded and the guidewire could not
proceed further, we punctured another duct.
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Fig. 1. —Photograph shows puncture set for single-wall puncture
technique. Sixty-centimeter, 0.018-inch guidewire is introduced into puncture
needle with its tip positioned in needle tip (arrow).
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Fig. 2A. —Single-wall puncture in 57-year-old man with carcinoma of
pancreas head. Cholangiogram was obtained using single-wall puncture
technique. Note ductal puncture (arrow) made at periphery of right
hepatic duct, 3 cm from liver capsule.
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Fig. 2B. —Single-wall puncture in 57-year-old man with carcinoma of
pancreas head. Cholangiogram obtained after further injection of contrast
medium shows numerous dilated bile ducts that might have been damaged by
conventional double-wall puncture technique.
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In group B, we used the conventional double-wall puncture technique. The
needle was advanced to 1-2 cm from the vertebral column or 2-3 cm inferior to
the dome of the liver. The stylet was removed, and a connecting tube was
attached to the hub for contrast medium injection. Contrast medium was
injected continuously while the needle was slowly withdrawn. After a duct was
entered, radiographs were obtained and the same sequential steps were
repeated.
In both groups, the mean RBC was measured from the bile specimens sampled
on postprocedural day 1 and then on postprocedural day 3 or 4. The number of
punctures needed to reach the bile duct and the depth of needle tracts from
the skin to the punctured duct in the two groups were measured and compared.
Complications were also recorded for both groups. The chi-square test was used
for analysis of the data. A p value of less than 0.05 was defined as
statistically significant.
Results
All procedures were technically successful in both groups. The mean RBC of
the bile specimen in group A was 4.2 x 106/µL and 10.2
x 106/µL in group B (p < 0.05). In most
patients, this hemobilia subsided within 2-3 days in both groups. The mean
depth of the needle tract in group A was 6.02 cm (range, 2.3-8.5 cm) and was
7.72 cm (range, 6.0-9.5 cm) in group B (p < 0.05). The mean number
of punctures was 1.7 (range, 1-3) in group A and 2.6 (range, 1-7) in group B,
but the difference was not significant. One patient in group B developed gross
hemobilia 3 days after the procedure as a result of traction of the
percutaneous transhepatic biliary drainage catheter; this was alleviated by
catheter manipulation. Transient fever (37.5-38°C) was noted in one
patient in group A and in two patients in group B. No other significant
bleeding or other complications were observed in either group.
Discussion
In most institutions, percutaneous transhepatic biliary drainage is
considered as an alternative when the patient is not a surgical candidate for
the treatment of benign or malignant biliary obstruction. The double-wall
puncture technique [3] has
relatively low morbidity and mortality rates in patients with obstructive
jaundice. However, occasionally disastrous hemorrhagic complications may
develop after percutaneous transhepatic biliary drainage in patients with
impaired coagulation and minimally dilated peripheral bile ducts. Patients
with cholangitis, in particular, may also carry the risk of septicemia when
infected bile flows into vessels
[4].
In general, percutaneous drainage procedures are performed via the shortest
distance from the skin to the target area to avoid vital organs and vascular
structures, but with the conventional double-wall puncture technique, multiple
blood vessels and other small bile ducts might be penetrated as the needle
proceeds forward from the skin to the punctured duct. This can lead to
hemorrhagic complications such as intrahepatic hematoma, traumatic
pseudoaneurysm, or hemobilia. Cases of bile leakage and peritonitis have also
been reported [2,
5-7]
when the conventional double-wall puncture method was used. In a preliminary
study, we frequently observed the needle passing through either portal or
hepatic veins, even when the bile duct was successfully punctured using the
double-wall puncture technique.
Liver puncture can now be performed with relative safety and accuracy using
sonographic guidance [5,
8]. However, small intrahepatic
vessels occasionally cannot be visualized, and vascular injuries may occur,
leading to hemorrhagic complications
[9]. Goodwin et al.
[10] described a simple method
that used a 22-gauge needle before placement of a percutaneous transhepatic
biliary drainage catheter, which could be implemented to access a peripheral
duct. In Goodwin's method, a 0.018-inch wire is advanced into the central
biliary tree after ductal puncture. The triaxial catheter set is then passed
over the wire, and the inner stylet and catheter are removed. A hemostatic
valve is attached to the outer sheath over the indwelling guidewire. The
guidewire is held in place, the outer sheath is withdrawn slowly, and diluted
contrast material is injected under fluoroscopic observation. However,
Goodwin's study uses the conventional double-wall method, and thus it still
does not resolve the problems associated with vascular injury.
With our single-wall puncture technique, ductal puncture begins at the
liver capsule and slowly advances toward the hepatic parenchyma until the
needle meets the bile ducts. Inadvertent vascular injury can thus be avoided
and the risk of hemorrhagic complication reduced. Our study indicates that the
single-wall puncture technique is safer and more efficacious than the
double-wall puncture method.
In our single-wall puncture technique, we experienced some difficulty in
injecting contrast medium through a needle into which a 0.018-inch wire was
inserted. Although this sometimes required a high injection pressure, no
complications such as subcapsular bleeding developed. There were no cases in
which continuous injection of contrast medium obscured the fluoroscopic field
and prevented us from completing the procedure.
No significant complications appeared in either group, in spite of a
significant difference in RBC in postprocedural bile specimens. Perhaps the
significant difference in RBC between the two methods was related to the
improved safety advantage of the single-wall puncture technique. Because the
single-wall puncture technique avoids undesirable vascular punctures, it can
be considered safer than the double-wall alternative. Furthermore, the fact
that the single-wall puncture can reduce the number of vessels transgressed,
providing a greater margin of safety, may be explained by the significantly
shorter length of needle pass in our sample.
In conclusion, the single-wall puncture method is useful in percutaneous
transhepatic biliary drainage and may be safer than the conventional
double-wall puncture method, reducing the risk of postprocedural
hemorrhage.
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Abstract
Introduction
