1139 FINE-NEEDLE PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY
patient with cholestatic jaundice, oral or intracholangiography will not succeed if the serumbilirubin is above 70 umol per litre. When investigations suggest an obstructive lesion rather than intrahepatic cholestasis, further information can be obtained from percutaneous transhepatic cholangiography--direct introduction of radio-opaque contrast medium into the biliary system. Diagnostic laparotomy for obstructive jaundice should, in fact, be a thing of the past. Originally, transhepatic cholangiography was done by the anterior approach with a sheathed needle: aspiration of bile shows that the biliary system has been entered. But IN
a
venous
with this method cannulation of undiluted ducts is often impossible.’ It is now giving way to the lateral approach with a fine needle-the Okuda, Chiba, or skinny needle - which gives a higher success-rate, is less traumatic, and requires nothing more elaborate than conventional fluoroscopic equipment with image intensification. Since the first reports, in Japanese in 19692 and in English in 1974,3 several groups have evaluated this fine-needle
technique.4-10 The investigation is done with the patient supine on the screening table, sedated usually with intravenous diazepam. The needle with stylet is inserted horizontally into the liver in the mid-axillary line after local anwsthesia of the appropriate intercostal space, determined by the position of the liver on preliminary X-ray and the area of dullness to percussion. Radio-opaque markers near the site of entry and over the xiphoid process are helpful. The needle is advanced until its tip is about 3 cm short of the right border of the vertebral column. Hinde et al,9 advocate directing the needle parallel to and 5-10 cm above the margin of the liver, to cross the path of the maximum number of bileducts. The flexibility of the needle allows for normal respiration during the procedure. After removal of the stylet radio-opaque contrast medium is injected continuously under fluoroscopic vision while the needle is slowly withdrawn. Pain usually means that contrast medium has been injected under the liver capsule, when the needle has been advanced too far or in the wrong direction. The outline of hepatic or portal-vein radicles, or lymphatic ducts, is easily distinguished from that of bileducts.6 20-30 ml of contrast medium will outline a dilated biliary system, and if the common bileduct is not at first visible, late films must be taken.6,8 If bileducts are not seen during withdrawal, the needle is reinserted in a slightly different direction. The success-rate for bileduct display has varied from 57% to 98%,7 and depends partly on the final diagnosis of the patients investigated since normal-sized bileducts are harder to enter than dilated ones. Redeker and 1. Hines, C. H., Ferrante, W. A., Davis, W. D., Tutton, R. A. Am. J. dig. Dis. 1972, 17, 868. 2. Tsuchiya, Y. Jap. J. Gastroent. 1969, 66, 438. 3. Okuda, K., Tanikawa, K., Emura, T., Kuratomi, S., Jinnouchi, S., Urabe,
K., Sumikoshi, T., Kanda, Y., Fukuyama, Y., Musha, H., Mori, H., Shimokawa, Y., Yakushiji, F., Matsuura, Y. Am. J. dig. Dis. 1974, 19, 21. 4. Redeker, A. G., Karvountzis, G. G., Richman, R. H., Horisawa, M. J. Am. med. Ass. 1975, 231, 386. 5. Elias, E., Hamlyn, A. N., Jain, S., Long, R. G., Summerfield, J. A., Dick, R., Sherlock, S. Gastroenterology, 1976, 71, 439. 6. Jain, S., Long, R. G., Scott, J., Dick, R., Sherlock, S. Br. J. Radiol. 1977,
others4 maintain that failure to enter a bileduct after six insertions of the needle virtually excludes biliary-tract obstruction, but not everyone agrees. Since the procedure is usually well tolerated there is no reason to limit the number of insertions to six. In one series cannulation was successful in 95% of patients with non-dilated bileducts.7 The procedure is reasonably safe, but haemostasis must be near-normal and antibiotic treatment should be started beforehand. Septicaemia can follow, particularly in patients with large-duct obstruction and previous episodes of cholangitis, and this has caused at least one death.1O Safety in these circumstances probably depends on the ability to aspirate bile through the needle after delineation of the biliary tract. This in turn may be related to differences in the internal diameter of the various needles in use. The feasibility of aspirating bile and thus decompressing an obstructed biliary tract influences the decision about early surgery to relieve obstruction. In a patient with recent episodes of cholangitis a reasonable policy would be to operate immediately when bile cannot be aspirated from an obstructed biliary tract. Although Hinde et al.9 obtained good results (97% successful bileduct display) using a very fine needle of 0.3 mm external diameter, this needle is surely the least capable of aspirating bile. In very ill patients with deep jaundice, continuous draining of bile by anterior or lateral insertion of a flexible cannulall,12 will avert the need for early surgery with its complications of hypotension and oliguria. With endoscopic retrograde cholangiography as a complementary or alternative procedure, bileducts can now be displayed radiographically in nearly every patient.’° Computerised tomography and grey-scale ultrasonography are also proving useful, and they may eventually be as accurate as direct cholangiography in showing the cause of obstructive jaundice. ORLOV A DELEGATION from the U.S. National Academy of Sciences has cancelled a trip to Moscow in protest against the Soviet Union’s treatment of the physicist, Yuri Orlov; and the whole future of the American/ Soviet scientific exchange programme is said to be in the balance." Orlov was one of a group who tried to monitor the Soviet Union’s compliance with the section of the Helsinki Agreement which concerned human rights. After a trial in which he was forbidden to call witnesses in his own defence (the defence being that his accusations were true), he was sentenced to seven years’ hard labour and five years’ internal exile for "anti-Soviet agitation and propaganda". The N.A.S. group’s reaction was understandable but wrong. How many of their would-be hosts will learn the reason for their non-arrival ? Personal contacts between scientists are one of the few reliable means of communication between East and West. This paragraph will doubtless be excised from copies of The Lancet reaching the Soviet Union. But no censor can keep Orlov out of a conversation begun by visitors to his country. 9. 10.
50, 175.
7. Pereiras, R., Chiprut, Med.
R.
O., Greenwald, R. A., Schiff, E. R. Ann. intern.
11.
83.
1977, 86, 562.
8. Lavelle, M. I., Owen, J. R.,
28, 453.
Hinde, G. De B., Smith, P. M., Craven, J. L. Gut, 1977, 18, 610. Benjamin, I. S., Allison, M. E. M., Moule, B., Blumgart, L. H. Br. J. Surg. 1978, 65, 92. Takada, T., Hanyu, F., Kobayashi, S., Uchida, Y. J. surg. Oncol. 1976, 8,
McNulty, S., Hamlyn, A.
N. Clin. Radiol.
1977,
Nakayama, T., Ikeda, A., Okuda, K. Gastroenterology, 1978, 74, 554. 13. Times, May 22, 1978.
12.
patient with cholestatic jaundice, oral or intracholangiography will not succeed if the serumbilirubin is above 70 umol per litre. When investigations suggest an obstructive lesion rather than intrahepatic cholestasis, further information can be obtained from percutaneous transhepatic cholangiography--direct introduction of radio-opaque contrast medium into the biliary system. Diagnostic laparotomy for obstructive jaundice should, in fact, be a thing of the past. Originally, transhepatic cholangiography was done by the anterior approach with a sheathed needle: aspiration of bile shows that the biliary system has been entered. But IN
a
venous
with this method cannulation of undiluted ducts is often impossible.’ It is now giving way to the lateral approach with a fine needle-the Okuda, Chiba, or skinny needle - which gives a higher success-rate, is less traumatic, and requires nothing more elaborate than conventional fluoroscopic equipment with image intensification. Since the first reports, in Japanese in 19692 and in English in 1974,3 several groups have evaluated this fine-needle
technique.4-10 The investigation is done with the patient supine on the screening table, sedated usually with intravenous diazepam. The needle with stylet is inserted horizontally into the liver in the mid-axillary line after local anwsthesia of the appropriate intercostal space, determined by the position of the liver on preliminary X-ray and the area of dullness to percussion. Radio-opaque markers near the site of entry and over the xiphoid process are helpful. The needle is advanced until its tip is about 3 cm short of the right border of the vertebral column. Hinde et al,9 advocate directing the needle parallel to and 5-10 cm above the margin of the liver, to cross the path of the maximum number of bileducts. The flexibility of the needle allows for normal respiration during the procedure. After removal of the stylet radio-opaque contrast medium is injected continuously under fluoroscopic vision while the needle is slowly withdrawn. Pain usually means that contrast medium has been injected under the liver capsule, when the needle has been advanced too far or in the wrong direction. The outline of hepatic or portal-vein radicles, or lymphatic ducts, is easily distinguished from that of bileducts.6 20-30 ml of contrast medium will outline a dilated biliary system, and if the common bileduct is not at first visible, late films must be taken.6,8 If bileducts are not seen during withdrawal, the needle is reinserted in a slightly different direction. The success-rate for bileduct display has varied from 57% to 98%,7 and depends partly on the final diagnosis of the patients investigated since normal-sized bileducts are harder to enter than dilated ones. Redeker and 1. Hines, C. H., Ferrante, W. A., Davis, W. D., Tutton, R. A. Am. J. dig. Dis. 1972, 17, 868. 2. Tsuchiya, Y. Jap. J. Gastroent. 1969, 66, 438. 3. Okuda, K., Tanikawa, K., Emura, T., Kuratomi, S., Jinnouchi, S., Urabe,
K., Sumikoshi, T., Kanda, Y., Fukuyama, Y., Musha, H., Mori, H., Shimokawa, Y., Yakushiji, F., Matsuura, Y. Am. J. dig. Dis. 1974, 19, 21. 4. Redeker, A. G., Karvountzis, G. G., Richman, R. H., Horisawa, M. J. Am. med. Ass. 1975, 231, 386. 5. Elias, E., Hamlyn, A. N., Jain, S., Long, R. G., Summerfield, J. A., Dick, R., Sherlock, S. Gastroenterology, 1976, 71, 439. 6. Jain, S., Long, R. G., Scott, J., Dick, R., Sherlock, S. Br. J. Radiol. 1977,
others4 maintain that failure to enter a bileduct after six insertions of the needle virtually excludes biliary-tract obstruction, but not everyone agrees. Since the procedure is usually well tolerated there is no reason to limit the number of insertions to six. In one series cannulation was successful in 95% of patients with non-dilated bileducts.7 The procedure is reasonably safe, but haemostasis must be near-normal and antibiotic treatment should be started beforehand. Septicaemia can follow, particularly in patients with large-duct obstruction and previous episodes of cholangitis, and this has caused at least one death.1O Safety in these circumstances probably depends on the ability to aspirate bile through the needle after delineation of the biliary tract. This in turn may be related to differences in the internal diameter of the various needles in use. The feasibility of aspirating bile and thus decompressing an obstructed biliary tract influences the decision about early surgery to relieve obstruction. In a patient with recent episodes of cholangitis a reasonable policy would be to operate immediately when bile cannot be aspirated from an obstructed biliary tract. Although Hinde et al.9 obtained good results (97% successful bileduct display) using a very fine needle of 0.3 mm external diameter, this needle is surely the least capable of aspirating bile. In very ill patients with deep jaundice, continuous draining of bile by anterior or lateral insertion of a flexible cannulall,12 will avert the need for early surgery with its complications of hypotension and oliguria. With endoscopic retrograde cholangiography as a complementary or alternative procedure, bileducts can now be displayed radiographically in nearly every patient.’° Computerised tomography and grey-scale ultrasonography are also proving useful, and they may eventually be as accurate as direct cholangiography in showing the cause of obstructive jaundice. ORLOV A DELEGATION from the U.S. National Academy of Sciences has cancelled a trip to Moscow in protest against the Soviet Union’s treatment of the physicist, Yuri Orlov; and the whole future of the American/ Soviet scientific exchange programme is said to be in the balance." Orlov was one of a group who tried to monitor the Soviet Union’s compliance with the section of the Helsinki Agreement which concerned human rights. After a trial in which he was forbidden to call witnesses in his own defence (the defence being that his accusations were true), he was sentenced to seven years’ hard labour and five years’ internal exile for "anti-Soviet agitation and propaganda". The N.A.S. group’s reaction was understandable but wrong. How many of their would-be hosts will learn the reason for their non-arrival ? Personal contacts between scientists are one of the few reliable means of communication between East and West. This paragraph will doubtless be excised from copies of The Lancet reaching the Soviet Union. But no censor can keep Orlov out of a conversation begun by visitors to his country. 9. 10.
50, 175.
7. Pereiras, R., Chiprut, Med.
R.
O., Greenwald, R. A., Schiff, E. R. Ann. intern.
11.
83.
1977, 86, 562.
8. Lavelle, M. I., Owen, J. R.,
28, 453.
Hinde, G. De B., Smith, P. M., Craven, J. L. Gut, 1977, 18, 610. Benjamin, I. S., Allison, M. E. M., Moule, B., Blumgart, L. H. Br. J. Surg. 1978, 65, 92. Takada, T., Hanyu, F., Kobayashi, S., Uchida, Y. J. surg. Oncol. 1976, 8,
McNulty, S., Hamlyn, A.
N. Clin. Radiol.
1977,
Nakayama, T., Ikeda, A., Okuda, K. Gastroenterology, 1978, 74, 554. 13. Times, May 22, 1978.
12.
