PROCEDURES:
1. Percutaneous Transhepatic Cholangiogram
2. Cholangioplasty and balloon sweep of the common bile duct.
3. Internal/External Biliary Drainage Catheter Placement
CLINICAL HISTORY:
CATHETER: 12 French Cook internal/external biliary drain
FLUOROSCOPY TIME: minutes
CONTRAST: 40 ml nonionic contrast
PROCEDURE:
The risks, benefits, and alternatives to the procedure and sedation were explained to the patient. Informed consent was obtained.
The anterior abdominal wall and right flank were prepped and draped in standard sterile fashion. An appropriate skin entry site was identified using fluoroscopy and ultrasound, and anesthetized with local. Under fluoroscopic guidance, a 22G Chiba needle was advanced into the liver. A bile duct was entered and the anterior right biliary system was opacified with contrast. Cholangiogram images were obtained.
Attention was then directed to cannulating the posterior right biliary ducts. Under fluoroscopic guidance, 22-gauge Chiba needle was advanced into the liver. A posterior right biliary duct was entered and the biliary system was opacified with contrast. Cholangiogram images were obtained.
A suitable duct for drain placement was identified on the right. Under direct fluoroscopic guidance, a right posterior duct was accessed with a third 22 gauge Chiba needle. A 0.018″ wire was passed centrally, and the needle exchanged for a 6 French transitional catheter. The inner stiffener, dilator, and guidewire were removed and contrast was injected to confirm location. A 0.035″ glidewire and 4 French glidecatheter were negotiated into the small bowel. The glidewire was removed and contrast was injected to confirm location. A 0.035″ Lunderquist wire was placed through the catheter. The access site was serially dilated and a 10 French sheath placed. Through the sheath a V 18 wire and 4 French Kumpe catheter were used to traverse the small bowel. The Kumpe catheter was removed.
Over the V18 0.018-in wire a 8 mm x 2 centimeter cutting balloon was used to dilate the area of ampullary stricture. The cutting balloon was removed and the common duct was angioplastied utilizing a 10 mm x 2 cm conquest balloon. The balloon was removed and a 5 French Fogarty balloon was utilized to balloon sweep of the common bile duct several times. The sheath, V 18 wire and plasty balloon were removed
Finally, a 12 French internal-external biliary drain was placed over the wire. The cope loop was formed and locked in the duodenum. The side holes were positioned such that the proximal sidehole was within the biliary duct. Contrast was injected to confirm location. The catheter was secured to the skin with 2-0 Ethilon and attached to gravity drainage. A sterile dressing was applied.
The procedure was well tolerated, and the patient discharged from the angiography suite in satisfactory condition.
FINDINGS:
1. Cholangiography demonstrates moderate dilation of both the anterior and posterior right hepatic ducts. The left system was not visualized purposefully to avoid over distention and sepsis.
2. Sheath cholangiography demonstrates filling defects within the common duct, some of which probably represents the patient’s known stone and some of which represents blood products.
3. Following cholangioplasty and balloon sweep, the extrahepatic bile ducts have markedly decreased in size and no further filling defects are seen in the common duct. A small amount of irregular material in the right sided intrahepatic ducts likely represents blood products.
IMPRESSION:
1. Moderate biliary ductal dilation due to choledocholithiasis.
2. Markedly improved appearance of the bile ducts following cholangioplasty and balloon sweep.
3. Successful placement of 12 French internal/external biliary drain via a peripheral right duct.