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    Cards (24)

    • External biliary drainage

      This is achieved following transhepatic cannulation of the biliary tree as described previously
    • Internal biliary drainage

      This can be achieved following transhepatic (as described previously) or endoscopic cannulation of the biliary tree
    • Percutaneous drainage catheter

      May allow internal or external drainage with side holes above and below the point of obstruction
    • ERCP
      An endoprosthesis or stent is placed to drain bile from above a stricture or to prevent obstruction by a stone in the duct
    • Indications
      • Malignant biliary stricture
      • Benign stricture following balloon dilatation
    • Contraindications are as for PTC
    • Contrast Media
      LOCM 200 mg I mL−1; 20–60 mL
    • Equipment
      • Wide-channelled endoscope for introduction of endoprosthesis by ERCP
      • Biplane fluoroscope facility is useful but not essential for transhepatic puncture
      • Set including guidewires, dilators and endoprosthesis
    • Transhepatic technique
      1. Perform percutaneous transhepatic cholangiogram
      2. Choose a duct in the right lobe of the liver with horizontal or caudal course
      3. Study the duct on US and insert 22G Chiba needle under US or fluoroscopic guidance
      4. Use coaxial introducer system over 0.018 guidewire to allow 0.035 wire and catheter access
      5. If duct not successfully punctured, withdraw Chiba needle but leave in liver capsule for further attempt
      6. Once 0.035 wire established, insert sheath e.g. 7-F
      7. Drain bile through side arm of sheath while manipulating catheter over wire
      8. For internal drainage or stent, pass wire and catheter through stricture into duodenum or jejunal loop
      9. For external drainage, insert suitable catheter over wire after sheath withdrawn
      10. May need variety of wires and catheters to cross difficult strictures
      11. If fails, institute external drainage and attempt to pass stricture again in a few days
      12. May place internal/external catheter across stricture and secure to skin
      13. May position and deploy metal biliary stent across malignant stricture
      14. May require balloon dilatation before or after stent deployment
      15. May leave temporary external drainage tube for 24-48 hours
    • Endoscopic technique

      1. Perform cholangiography following cannulation of biliary tree
      2. Perform endoscopic sphincterotomy
      3. Place guidewire via endoscope channel through sphincter and push past stricture under fluoroscopic guidance
      4. After dilating stricture, push endoprosthesis (plastic stent) over guidewire and site with side-holes above and below stricture
      5. Metal biliary stents can also be placed at ERCP when appropriate
    • Aftercare
      • As for percutaneous transhepatic cholangiography
      • Antibiotics for at least 3 days
      • Externally draining catheter should be regularly flushed with normal saline and exchanged at 3-monthly intervals
    • Percutaneous transhepatic cholangiography

      1. Dilate stricture
      2. Push endoprosthesis (plastic stent) over guidewire and site with side-holes above and below stricture
    • Metal biliary stents can also be placed at ERCP when appropriate
    • Aftercare
      1. As for percutaneous transhepatic cholangiography
      2. Antibiotics for at least 3 days
      3. Externally draining catheter should be regularly flushed with normal saline and exchanged at 3-monthly intervals
    • Complications
      • Sepsis
      • Dislodgement of catheters, endoprostheses
      • Blockage of catheters/endoprostheses
      • Perforation of bile duct above the stricture on the passage of guidewire
    • Percutaneous extraction of retained biliary calculi (Burhenne technique)

      Extraction of retained biliary calculi through the skin
    • Indications
      • Retained biliary calculi seen on the T-tube cholangiogram (incidence 3%)
    • Contraindications
      • Small T-tube (<12-F)
      • Tortuous T-tube course in soft tissues
      • Acute pancreatitis
      • Drain in situ (cross connections exist between the drain tract and the T-tube tract)
    • Contrast medium

      HOCM or LOCM 150 mg I mL^-1 (low-density contrast medium is used to avoid obscuring the calculus)
    • Equipment
      • Fluoroscopy unit with spot film device
      • Steerable catheter system with wire baskets
    • Patient preparation
      1. Prophylactic antibiotics and pre-medication 1 hour prior to the procedure
      2. Analgesia during the procedure
    • Technique
      1. Patient lies supine on x-ray table, PTC performed if no biliary drainage catheter
      2. Drainage catheter removed over guidewire, sheath inserted into ducts
      3. Contrast injected to identify presence and location of stones and strictures
      4. If stricture, advance biliary manipulation catheter and guidewire across it, commence balloon dilatation
      5. Attempt to dislodge stones with balloons into Roux loop
      6. If unsuccessful, pass Dormier basket through sheath and attempt to catch stone
      7. Advance basket into Roux loop and release stone
      8. Remove basket
      9. Pass guidewire, remove sheath, place biliary drainage catheter
      10. Intermittently inject contrast media to clarify position of stones
    • Aftercare
      1. Pulse and blood pressure half-hourly for 6 hours
      2. Bed rest for 4-6 hours
    • Complications
      • Allergic reactions to contrast medium (rare)
      • Pancreatitis
      • Fever
      • Perforation of T-tube tract
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