Clio. Radiol. (1979) 30, 451-455
Diagnostic Value of Percutaneous Transhepatic Cholangiography Judged by Personal Experience of 58 Patients NAOFUMI NAGASUE and KIYOSHI INOKUCHI
From the Second Department o f Surgery, Kyushu University School of Medicine, Fukuoka 812, Japan During the last seven years percutaneous transhepatic cholangiography (PTC) using a fine needle was performed in 58 patients. The biliary tract was visualised and opacified in the 52 patients with dilated biliary ducts. The correct diagnoses were made in 51 of them. In six patients with a non-dilated biliary system, successful PTC was carried out with the correct diagnoses in four of them. There were four non-fatal complications; two septic reactions, one haemobilia, and one subcapsular haematoma, but all were controlled by conservative treatment alone. The PTC with a fine needle is an accurate, useful and safe procedure of choice for the diagnosis of obstructive jaundice and jaundice of obscure origin. It is useful in distinguishing hepatocellular jaundice from obstructive jaundice thus preventing an unnecessary operation. Failure to visualise the biliary tract by an experienced hand strongly indicates that the jaundice is non-obstructive.
INTRODUCTION Many previous reports have indicated that percutaneous transhepatic cholangiography (PTC) is a very useful method for distinguishing between obstructive and non-obstructive jaundice. A successful PTC gives extremely important information not only for the diagnosis of jaundice but for its proper management. The presence or absence of bilialy tract obstruction, and the location and nature of the obstruction, may be determined. Previously, complications such as bile leakage and bleeding had been occasionally observed after PTC because of the larger size of the needle, so most authors had recommended an immediate operation following the examination. However, the recent use of the fine needle first reported by Okuda and his associates (1974) has reduced these complications and, moreover, brought about a higher successful rate of biliary tract opacification. Since 1970, one of the authors (N.N.) has performed PTC in 55 jaundiced and three non-jaundiced patients. In this communication the diagnostic value and safety of PTC with a fine needle is presented.
MATERIALS AND METHODS Candidates for percutaneous transhepatic cholangiography (PTC) were patients with obstructive and suspected obstructive jaundice. Those who had a haemorrhagic tendency or ascites were excluded from the examination until these were corrected, A fine needle 15cm long and 0.7mm in external diameter was used for the puncture. Under fluoroscopic
control the puncture was performed through the right midaxillary line with the patient supine. The needle was inserted horizontally towards the 12th thoracic vertebral body. The mandrin was removed, and a 10ml syringe with connecting tube filled with saline were attached to the needle. The needle was withdrawn until a bile flow was obtained. If a bile flow could not be obtained the needle was inserted and a small amount of 60% Urografin was injected as the needle was slowly withdrawn. When the ducts were opacified, the tip of the needle was left in position. As much bile as possible was aspirated, and following this the contrast media was slowly injected. Appropriate radiographs were taken under screen control. In the patients with complete biliary tract obstruction, bile mixed with contrast media was aspirated before withdrawal of the needle. Twenty-nine patients were males and 29 were females. The ages ranged from 21 to 79 years old. The final diagnosis was confirmed by operation in 42 patients, by autopsy in two, by post-mortem liver biopsy in one, and by the combination of clinical course, liver function tests, scintigraphy, angiography and PTC in the remaining 12 patients. Thirty-nine patients were operated upon between 1 and 25 days after PTC. PTC was performed only once in each patient except for a patient with cholestatic hepatitis in whom the examination was repeated three times during the course of a week. In the last 12 patients percutaneous transhepatic bile drainage was carried out as preoperative preparation, or as permanent drainage in patients with inoperable pathology.
CLINICAL RADIOLOGY
452
Table 1 - Group 1, malignant disorders
Cancer of head of pancreas Cancer of Vater papilla Cholangioma Cancer of gallbladder Intraductal growth of hepatoma Extraduetal compression by lymph node Gastric cancer Hodgkin's disease Total Table 2 - Group 2, benign disorders
Choledocholithiasis Hepatolithiasis Gallstone + cholangitis Cholecystitis Benign biliary stricture Haemobilia Choledochal cyst Hepatitis Fulminant Cholestatic Total
No. of patients
Dilated Entry ducts
Correct diagnosis
13 3 2 1 1 1 1
13 2 2 0 1 1 l
13 2 2 1 1 1 l
12/13 2/3 2/2 l /1 1/1 1/1 1/1
1 3 26
0 0 20
1 2 24
1] 1 2]3 23/26
Antibiotics were administered prior to and after PTC only in the patients who had symptoms and signs of cholangitis. RESULTS The results are summarised in Tables 1 and 2, classified by aetiology. The overall successful rate of PTC was 94.8%. There was no fatality from the examinations. Group I - Malignant Disorders (Table 1) All of the 32 patients with malignant obstructive jaundice had dilated biliary ducts, and file visualisation and opacification of the system was achieved in all cases. The preoperative diagnosis proved to be correct in all instances, although ancillary diagnostic methods such as coeliac arteriography, radionuclide scanning of the liver and pancreas, or hypotonic duodenography were evaluated in combination with PTC in most patients, especially in equivocal cases (Fig. 1). Artedography, duodenography and pancreatic scan helped to differentiate carcinoma of the head of the pancreas from cholangioma of the distal common bile duct (Fig. 2). Two patients with gall-
No. o f patients
Dilated ducts
Entry
Correct diagnosis
8 1 11 2 2
8 1 11 2 2
8 1 11 2 2
8/8 1/1 11/11 2/2 2/2
7 1 32
7 1 32
7 1 32
7/7 1/1 32/32
bladder cancer showed angiographic abnormalities of the cystic arteries as well as obstruction of the common hepatic duct. In two patients of hepatoma, the cause of jaundice was due to the intraductal growth of liver cell carcinoma (Fig. 3). Group II - Benign Disorders (Table 2) This group was composed o f 26 patients. There was slight to severe jaundice in all patients except for three; two with choledocholithiasis (Fig. 4) and one with hepatolithiasis (Caroli's disease). An erroneous preoperative diagnosis was made in one patient due to insufficient contrast medium. Correct diagnoses were made in the remaining patients with obstructive jaundice (Fig. 5). In three of four patients with hepatitis the biliary tracts were opacified (Fig. 6). In one patient with cholestatic hepatitis, PTC was repeated three times during the week before opera. tion. All resulted in failure to visualise the biliary system. Although colestatic hepatitis was believed to be the most likely diagnosis, the patient had periodic pains in the right upper quadrant and the jaundice continued to increase in spite of the administration of corticosteroids. It was decided that exploratory laparotomy be carded out with the subsequent confirmation of hepatitis. Postoperatively he suffered from a severe haemorrhagic diathesis which continued until his death two days later. Complications There were no fatal complications in the present series. Four patients had complications obviously due to the PTC and which subsided only with medical treatment. Septic reaction was found in two patients; one with Klatskin tumour and the other with hepatolithiasis. Haemobilia was encountered in a patient with hepatolithiasis, and this ceased spontaneously. One female patient with choledocholithiasis complained of severe epigastdc pain following P~C. At
DIAGNOSTIC
VALUE
OF PERCUTANEOUS
Fig. 1 Extraductal compression of Itodgkin's disease. PTC demonstrates obstruction of the common hepatic duct.
TRANSHEPATIC
CHOLANGIOGRAPHY
453
Fig_ 2 - Cholangioma of the common bile duct. PTC demonstrates complete obstruction of the pancreatic portion of the common bile duct with typical tumour configuration. surgery performed on the following day a subcapsular haematoma was observed at the hepatic hilus. Although an immediate operation was not performed after PTC in most of the patients, obvious intraperitoneal haemorrhage and bile leakage were never encountered in our patients.
DISCUSSION
Fig. 3 lntraductal growth of liver cell carcinoma. PTC demonstrates shadow defect in the common hepatic and bile ducts. Catheter for drainage was introduced beyond the obstruction.
In the present series of 58 patients in whom percutaneous transhepatic cholangiography (PTC) was performed and diagnosed by the same person, the usefulness and safety of the method have been established. The biliary tract was visualised in all of 52 patients with dilated ducts, three o f them having no jaundice. The diagnosis was incorrect in one patient because of the insufficient amount of contrast media injected, but this was an early case in the series. The PTC was successful in four of six patients with non-dilated biliary ducts. The two patients with non-visualised biliary trees suffered from cholestatic hepatitis and Caroli's disease of the left hepatic lobe containing impacted stones, respectively. In the former patient, three attempts at PTC resulted in no visualisation of the biliary tract. The jaundice increased steadily in spite of medical treatment with corticosteroids and the patient developed periodic
454
CLINICAL RADIOLOGY
Fig. 4 - Choledocholithiasis. PTC demonstrates large calculus in lower c o m m o n bile duct and marked dilatation of the biliary system.
Fig. 5 - Hepatolithiasis of bilateral hepatic lobes. PTC demonstrates numerous intrahepatic calculi.
pain in the right upper abdomen. Obstructive juandice could not be ruled out, and exploratory laparotomy was done. Following this unnecessary
laparotomy the patient developed a severe haemorrhagic tendency and hepatic failure followed by death two days later. This bitter experience prevented us from making the same error in later similar cases. Thus PTC proved to be extremely beneficial in diagnosing the position and nature of biliary obstruction and in differentiating obstructive from non-obstructive jaundice, thus preventing unnecessary laparotomy. There are several advantages in using a fine needle for PTC as postulated by several other investigators (Okuda e t al., 1974; Goldstein et al., 1977; Redeker et al., 1975). First, there are very few serious complications with the fine needle. In our patients, bile leakage never occurred in contrast with the experience of Juler and his associates (1977) who also used the Chiba needle. This difference can probably be explained by the technical differences. Juler et al. withdrew the needle from the liver after the injection of contrast material in all patients, whereas we aspirated bile without removing the needle, or performed a subsequent percutaneous bile drainage after PTC especially in patients with complete biliary obstruction. Secondly, an immediate operation is rarely necessary after PTC with a fine needle. We usually perform PTC as the first technique to diagnose the site and nature of obstruction. If there is no doubt that the lesion is benign such as choledocholithiasis or benign biliary stricture, further specific
Fig. 6 - Cholestatic hepatitis. PTC demonstrates no obstruction and dilatation of the biliary tract.
DIAGNOSTIC VALUE OF PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY examinations are unnecessary. If the lesion is suspected to be malignant, further studies such as arteriograpfiY, scanning (radionuclide or ultrasound or both) or endoscopy are carried out to determine the kind of malignancy and to assess its resectability. Thus there is no necessity for immediate laparotomy after PTC, an appropriate and economical order of diagnostic procedure. Thirdly, with the use of a fine needle the successful rate o f bile duct visualisation has become higher especially in patients without dilatation of the biliary trees compared with the previously employed thick needle (Arner et al., 1962). This is o f great value in avoiding unnecessary laparotomy in patients with non-obstructive jaundice of hepatocellular origin. Thus, in our recent experience, PTC with a fine needle is a highly accurate, useful and safe method for the diagnosis of obstructive jaundice of obscure origin. It is a valuable technique for distinguishing non-surgical jaundice from obstructive jaundice. Negative visualisation of the biliary tract by an
455
experienced hand indicates strongly that the jaundice is non-obstructive. REFERENCES
Arner, O., Hagberg, S. & Seldinger, S. I. (1962). Percutaneous transhepatic cholangiography: puncture of dilated and non-dilated bile ducts under roentgen control. Surgery, 52, 561-571. Goldstein, L. I., Kadell, B. M. & Weiner, M. (1977). Thin needle cholangiography: experience with 50 patients. Annals of Surgery, 186,602-606. Juler, G. L., Conroy, R. M. & Fuelleman, R- M. (1977). Bile leakage following percutaneous transhepatic cholangiography with the Chiba needle. Archives of Surgery, 112, 954-958. Okuda, K., Tanikawa, K., Emura, T. et al. (1974). Nonsurgical percutaneous transhepatic cholangiography: diagnostic significance in medical problems of the liver. American Journal of Digestive Diseases, 19, 21 36. Redeker, A. G., Karvountzis, G. G., Richman, R. H. et al. (1975). Percutaneous transhepatic cholangiography: an improved technique. Journal American Medical Association, 231,386 387.
Diagnostic Value of Percutaneous Transhepatic Cholangiography Judged by Personal Experience of 58 Patients NAOFUMI NAGASUE and KIYOSHI INOKUCHI
From the Second Department o f Surgery, Kyushu University School of Medicine, Fukuoka 812, Japan During the last seven years percutaneous transhepatic cholangiography (PTC) using a fine needle was performed in 58 patients. The biliary tract was visualised and opacified in the 52 patients with dilated biliary ducts. The correct diagnoses were made in 51 of them. In six patients with a non-dilated biliary system, successful PTC was carried out with the correct diagnoses in four of them. There were four non-fatal complications; two septic reactions, one haemobilia, and one subcapsular haematoma, but all were controlled by conservative treatment alone. The PTC with a fine needle is an accurate, useful and safe procedure of choice for the diagnosis of obstructive jaundice and jaundice of obscure origin. It is useful in distinguishing hepatocellular jaundice from obstructive jaundice thus preventing an unnecessary operation. Failure to visualise the biliary tract by an experienced hand strongly indicates that the jaundice is non-obstructive.
INTRODUCTION Many previous reports have indicated that percutaneous transhepatic cholangiography (PTC) is a very useful method for distinguishing between obstructive and non-obstructive jaundice. A successful PTC gives extremely important information not only for the diagnosis of jaundice but for its proper management. The presence or absence of bilialy tract obstruction, and the location and nature of the obstruction, may be determined. Previously, complications such as bile leakage and bleeding had been occasionally observed after PTC because of the larger size of the needle, so most authors had recommended an immediate operation following the examination. However, the recent use of the fine needle first reported by Okuda and his associates (1974) has reduced these complications and, moreover, brought about a higher successful rate of biliary tract opacification. Since 1970, one of the authors (N.N.) has performed PTC in 55 jaundiced and three non-jaundiced patients. In this communication the diagnostic value and safety of PTC with a fine needle is presented.
MATERIALS AND METHODS Candidates for percutaneous transhepatic cholangiography (PTC) were patients with obstructive and suspected obstructive jaundice. Those who had a haemorrhagic tendency or ascites were excluded from the examination until these were corrected, A fine needle 15cm long and 0.7mm in external diameter was used for the puncture. Under fluoroscopic
control the puncture was performed through the right midaxillary line with the patient supine. The needle was inserted horizontally towards the 12th thoracic vertebral body. The mandrin was removed, and a 10ml syringe with connecting tube filled with saline were attached to the needle. The needle was withdrawn until a bile flow was obtained. If a bile flow could not be obtained the needle was inserted and a small amount of 60% Urografin was injected as the needle was slowly withdrawn. When the ducts were opacified, the tip of the needle was left in position. As much bile as possible was aspirated, and following this the contrast media was slowly injected. Appropriate radiographs were taken under screen control. In the patients with complete biliary tract obstruction, bile mixed with contrast media was aspirated before withdrawal of the needle. Twenty-nine patients were males and 29 were females. The ages ranged from 21 to 79 years old. The final diagnosis was confirmed by operation in 42 patients, by autopsy in two, by post-mortem liver biopsy in one, and by the combination of clinical course, liver function tests, scintigraphy, angiography and PTC in the remaining 12 patients. Thirty-nine patients were operated upon between 1 and 25 days after PTC. PTC was performed only once in each patient except for a patient with cholestatic hepatitis in whom the examination was repeated three times during the course of a week. In the last 12 patients percutaneous transhepatic bile drainage was carried out as preoperative preparation, or as permanent drainage in patients with inoperable pathology.
CLINICAL RADIOLOGY
452
Table 1 - Group 1, malignant disorders
Cancer of head of pancreas Cancer of Vater papilla Cholangioma Cancer of gallbladder Intraductal growth of hepatoma Extraduetal compression by lymph node Gastric cancer Hodgkin's disease Total Table 2 - Group 2, benign disorders
Choledocholithiasis Hepatolithiasis Gallstone + cholangitis Cholecystitis Benign biliary stricture Haemobilia Choledochal cyst Hepatitis Fulminant Cholestatic Total
No. of patients
Dilated Entry ducts
Correct diagnosis
13 3 2 1 1 1 1
13 2 2 0 1 1 l
13 2 2 1 1 1 l
12/13 2/3 2/2 l /1 1/1 1/1 1/1
1 3 26
0 0 20
1 2 24
1] 1 2]3 23/26
Antibiotics were administered prior to and after PTC only in the patients who had symptoms and signs of cholangitis. RESULTS The results are summarised in Tables 1 and 2, classified by aetiology. The overall successful rate of PTC was 94.8%. There was no fatality from the examinations. Group I - Malignant Disorders (Table 1) All of the 32 patients with malignant obstructive jaundice had dilated biliary ducts, and file visualisation and opacification of the system was achieved in all cases. The preoperative diagnosis proved to be correct in all instances, although ancillary diagnostic methods such as coeliac arteriography, radionuclide scanning of the liver and pancreas, or hypotonic duodenography were evaluated in combination with PTC in most patients, especially in equivocal cases (Fig. 1). Artedography, duodenography and pancreatic scan helped to differentiate carcinoma of the head of the pancreas from cholangioma of the distal common bile duct (Fig. 2). Two patients with gall-
No. o f patients
Dilated ducts
Entry
Correct diagnosis
8 1 11 2 2
8 1 11 2 2
8 1 11 2 2
8/8 1/1 11/11 2/2 2/2
7 1 32
7 1 32
7 1 32
7/7 1/1 32/32
bladder cancer showed angiographic abnormalities of the cystic arteries as well as obstruction of the common hepatic duct. In two patients of hepatoma, the cause of jaundice was due to the intraductal growth of liver cell carcinoma (Fig. 3). Group II - Benign Disorders (Table 2) This group was composed o f 26 patients. There was slight to severe jaundice in all patients except for three; two with choledocholithiasis (Fig. 4) and one with hepatolithiasis (Caroli's disease). An erroneous preoperative diagnosis was made in one patient due to insufficient contrast medium. Correct diagnoses were made in the remaining patients with obstructive jaundice (Fig. 5). In three of four patients with hepatitis the biliary tracts were opacified (Fig. 6). In one patient with cholestatic hepatitis, PTC was repeated three times during the week before opera. tion. All resulted in failure to visualise the biliary system. Although colestatic hepatitis was believed to be the most likely diagnosis, the patient had periodic pains in the right upper quadrant and the jaundice continued to increase in spite of the administration of corticosteroids. It was decided that exploratory laparotomy be carded out with the subsequent confirmation of hepatitis. Postoperatively he suffered from a severe haemorrhagic diathesis which continued until his death two days later. Complications There were no fatal complications in the present series. Four patients had complications obviously due to the PTC and which subsided only with medical treatment. Septic reaction was found in two patients; one with Klatskin tumour and the other with hepatolithiasis. Haemobilia was encountered in a patient with hepatolithiasis, and this ceased spontaneously. One female patient with choledocholithiasis complained of severe epigastdc pain following P~C. At
DIAGNOSTIC
VALUE
OF PERCUTANEOUS
Fig. 1 Extraductal compression of Itodgkin's disease. PTC demonstrates obstruction of the common hepatic duct.
TRANSHEPATIC
CHOLANGIOGRAPHY
453
Fig_ 2 - Cholangioma of the common bile duct. PTC demonstrates complete obstruction of the pancreatic portion of the common bile duct with typical tumour configuration. surgery performed on the following day a subcapsular haematoma was observed at the hepatic hilus. Although an immediate operation was not performed after PTC in most of the patients, obvious intraperitoneal haemorrhage and bile leakage were never encountered in our patients.
DISCUSSION
Fig. 3 lntraductal growth of liver cell carcinoma. PTC demonstrates shadow defect in the common hepatic and bile ducts. Catheter for drainage was introduced beyond the obstruction.
In the present series of 58 patients in whom percutaneous transhepatic cholangiography (PTC) was performed and diagnosed by the same person, the usefulness and safety of the method have been established. The biliary tract was visualised in all of 52 patients with dilated ducts, three o f them having no jaundice. The diagnosis was incorrect in one patient because of the insufficient amount of contrast media injected, but this was an early case in the series. The PTC was successful in four of six patients with non-dilated biliary ducts. The two patients with non-visualised biliary trees suffered from cholestatic hepatitis and Caroli's disease of the left hepatic lobe containing impacted stones, respectively. In the former patient, three attempts at PTC resulted in no visualisation of the biliary tract. The jaundice increased steadily in spite of medical treatment with corticosteroids and the patient developed periodic
454
CLINICAL RADIOLOGY
Fig. 4 - Choledocholithiasis. PTC demonstrates large calculus in lower c o m m o n bile duct and marked dilatation of the biliary system.
Fig. 5 - Hepatolithiasis of bilateral hepatic lobes. PTC demonstrates numerous intrahepatic calculi.
pain in the right upper abdomen. Obstructive juandice could not be ruled out, and exploratory laparotomy was done. Following this unnecessary
laparotomy the patient developed a severe haemorrhagic tendency and hepatic failure followed by death two days later. This bitter experience prevented us from making the same error in later similar cases. Thus PTC proved to be extremely beneficial in diagnosing the position and nature of biliary obstruction and in differentiating obstructive from non-obstructive jaundice, thus preventing unnecessary laparotomy. There are several advantages in using a fine needle for PTC as postulated by several other investigators (Okuda e t al., 1974; Goldstein et al., 1977; Redeker et al., 1975). First, there are very few serious complications with the fine needle. In our patients, bile leakage never occurred in contrast with the experience of Juler and his associates (1977) who also used the Chiba needle. This difference can probably be explained by the technical differences. Juler et al. withdrew the needle from the liver after the injection of contrast material in all patients, whereas we aspirated bile without removing the needle, or performed a subsequent percutaneous bile drainage after PTC especially in patients with complete biliary obstruction. Secondly, an immediate operation is rarely necessary after PTC with a fine needle. We usually perform PTC as the first technique to diagnose the site and nature of obstruction. If there is no doubt that the lesion is benign such as choledocholithiasis or benign biliary stricture, further specific
Fig. 6 - Cholestatic hepatitis. PTC demonstrates no obstruction and dilatation of the biliary tract.
DIAGNOSTIC VALUE OF PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY examinations are unnecessary. If the lesion is suspected to be malignant, further studies such as arteriograpfiY, scanning (radionuclide or ultrasound or both) or endoscopy are carried out to determine the kind of malignancy and to assess its resectability. Thus there is no necessity for immediate laparotomy after PTC, an appropriate and economical order of diagnostic procedure. Thirdly, with the use of a fine needle the successful rate o f bile duct visualisation has become higher especially in patients without dilatation of the biliary trees compared with the previously employed thick needle (Arner et al., 1962). This is o f great value in avoiding unnecessary laparotomy in patients with non-obstructive jaundice of hepatocellular origin. Thus, in our recent experience, PTC with a fine needle is a highly accurate, useful and safe method for the diagnosis of obstructive jaundice of obscure origin. It is a valuable technique for distinguishing non-surgical jaundice from obstructive jaundice. Negative visualisation of the biliary tract by an
455
experienced hand indicates strongly that the jaundice is non-obstructive. REFERENCES
Arner, O., Hagberg, S. & Seldinger, S. I. (1962). Percutaneous transhepatic cholangiography: puncture of dilated and non-dilated bile ducts under roentgen control. Surgery, 52, 561-571. Goldstein, L. I., Kadell, B. M. & Weiner, M. (1977). Thin needle cholangiography: experience with 50 patients. Annals of Surgery, 186,602-606. Juler, G. L., Conroy, R. M. & Fuelleman, R- M. (1977). Bile leakage following percutaneous transhepatic cholangiography with the Chiba needle. Archives of Surgery, 112, 954-958. Okuda, K., Tanikawa, K., Emura, T. et al. (1974). Nonsurgical percutaneous transhepatic cholangiography: diagnostic significance in medical problems of the liver. American Journal of Digestive Diseases, 19, 21 36. Redeker, A. G., Karvountzis, G. G., Richman, R. H. et al. (1975). Percutaneous transhepatic cholangiography: an improved technique. Journal American Medical Association, 231,386 387.
