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1263
Percutaneous Dilatation of Benign Biliary Strictures: Single-Session Therapy
Michael J. Lee1 Peter R. Mueller Sanjay Saini Peter F. Hahn Steven
L. Dawson
with General
Anesthesia
Percutaneous biliary patients that presently
stricture dilatation (PBSD) is an uncomfortable procedure for requires multiple dilatation sessions spread over many days. We evaluated the use of general anesthesia to enable PBSD to be performed in a single sitting in 14 patients with benign biliary strictures (11 anastomotic and three iatrogenlc strictures). Four patients had multiple strictures, and the other 10 had a single stricture. Strictures were documented by transhepatic cholangiography (11 patients) or T-tube cholangiography (three); quantitative biliary perfusion studies were additionally performed In seven cases. Dilatation was performed transhepatically in 1 1 patients and via a T-tube track in three. Balloons ranged from 8 to 12 mm in diameter and were manually inflated for 3 mm with an average of five Inflations per stricture. Stenting catheters were left across the strictured areas in all patients for 6-21 days (mean, 10 days) before
removal. further
The mean duration
of hospital
stay for all patients
was 5.7 days, which
could
into means of 3.6 days (range, 1-6 days) for 11 patients without complications and 13.7 days (range, 13-14 days) for three patients who had complicatons. Complications included cholangitis; liver hematoma (which resolved with censorvative therapy in both cases); and pseudoaneurysm of the hepatic artery, which necessitated angiographic embolization. PBSD achieved long-term patency in 13 (93%) of 14
patients
be divided
with a follow-up
period of 2.0 to 5.5 years (mean, 3.2 years).
A
stricture
recurred
in one patient 1.5 years after dilatation. We conclude that PBSD with the patient under general anesthesia can be performed in a single visit to the radiology department with excellent long-term patency rates, a shorter hospital stay, and a pain-free procedure for the patient. AJR 157:1263-1266,
Received May 30, 1991; accepted July26, 1991.
after revision
I All authors: Department of Radiology, Massechusetts General Hosptal and Harvard Medical School, 32 Fruit St., Boston, MA 021 14. Address
reprint
requests
to P. R. Mueller.
0361-803X/91/1576-1263 © Amencan Roentgen
Ray Society
December
1991
Many previous reports have emphasized the importance of percutaneous biliary dilatation as an effective alternative to surgical management of benign biliary strictures [1 -7]. Complications of this procedure are usually minimal, and the main complications of sepsis and bleeding are easily controlled. However, pain during the procedure, especially at the time of balloon inflation, can be severe and has remained problematic. Because of associated pain, biliary dilatation is often performed in several sessions, usually spread over 1 0 to 1 4 days. This necessarily increases the duration of hospital stay and absence from employment for most patients. Various solutions to the problem of pain during dilatation have been proposed and include (1) wide local infiltration with lidocaine or bupivacaine coupled with the liberal use of IV narcotics and sedatives, (2) direct installation of lidocaine or bupivacaine into the biliary tree [1 8], or (3) administration of general anesthesia, if required. We used to perform biliary dilatation in at least three sessions during a 5- to 8day period and employed a combination of local anesthesia and IV sedatives and narcotics [3]. However, in the past 5 years we have used general anesthesia for control of pain. An added benefit of this approach is the freedom to perform the entire procedure from percutaneous transhepatic biliary drainage to biliary dilatation ,
LEE
1264
in one session. We report here our results and the complications we encountered in using this approach in 1 4 patients.
Materials
and Methods
Downloaded from www.ajronline.org by 117.245.43.132 on 10/06/15 from IP address 117.245.43.132. Copyright ARRS. For personal use only; all rights reserved
We retrospectively percutaneous
of benign
biliary
strictures
in the
last
5 years.
Fourteen patients (eight male, six female; age range, 1 2-77 years; mean age, 44 years) had percutaneous biliary stricture dilatation (PBSD) under general anesthesia. The cause of the biliary strictures was previous surgery for benign disease with anastomotic strictures (choledochojejunostomy, hepaticojejunostomy) in 1 1 patients, and iatrogenic
surgical
trauma
AJR:157,
In all cases,
during
cholecystectomy
in three
patients.
had
cholangiography. Alkaline phosphatase measured in all patients before dilatation, to be elevated
in eight. Alkaline
phosphatase
a stricture
seen
at T-tube
and bilirubin levels were and the levels were found and bilirubin
levels were
elevated in the remaining six patients during episodes of cholangitis, but had returned to normal before PBSD. Sonography or CT was performed in all patients before dilatation and revealed mildly dilated biliary ducts in seven patients and normal nondilated ducts in the remaining
seven.
The
presence
of a stricture
was
documented
biliary
obstruction
before
dilatation
in the
first
seven
the
patient
under
to seven). Ten- to 1 2-French stenting the strictured areas in all patients after
The end point for successful in all patients
by the
dilatation
disappearance
was established
of a balloon
waist
qualitatively
during
so that the strictured
duct returned to the size of the adjacent
duct.
the end point
Quantitatively,
by recording
of dilatation
biliary pressures
was
inflation
normal
established
in
after the procedure.
Long-term patency was determined of liver function tests in all patients
by clinical follow-up and results for a mean of 3.2 ± 1 .1 years
(range,
physical
function
2.0-5.5 tests
years). were
Repeated
done,
sepsis were documented. cholangiography
and
episodes
Additionally,
was repeated
to assess
examination
of cholangitis,
in two patients
and liver jaundice,
or
transhepatic
patency.
in all
patients by either transhepatic cholangiography (1 1 patients) or Ttube cholangiography (three patients). Provocative perfusion studies were used to make quantitative manometric determinations of functional
with
from gaining access to the biliary tree (transhe-
per stricture (range, three catheters were left across
seven patients
patients
performed
inflated for 3 mm during each inflation, with an average of five inflations
without
three
was
track) to stricture dilatation, was done in all under general anesthesia (Fig. 1). Biliary strictures were dilated by using techniques previously described [3]. Balloons varied between 8 and 12 mm in diameter and were reinforced to allow high inflation pressures. All balloons were manually
dilatation.
and
dilatation
1991
patically or via a T-tube cases with the patient
Four patients had two strictures each while the rest had one stricture each. Twelve strictures were located in the common bile duct, and six were in the intrahepatic right or left main ducts. No patients with scierosing cholangitis were treated during this period. Eleven patients had recurrent episodes of cholangitis with or jaundice,
biliary
December
general anesthesia. The transhepatic approach was used in 1 1 patients and a T-tube track was used in three patients. All strictures were between 1 and 5 mm in diameter and less than 2 cm in length.
The entire procedure,
reviewed the records of all patients referred for
dilatation
ET AL.
patients.
Biliary pressures were measured and perfusion tests performed as described by previous investigators [9]. Quantitative pressure studies were not done in the remaining seven patients, because clinical and radiologic data convincingly proved the presence of significant biliary strictures.
Results PBSD from initial transhepatic cholangiography to stricture dilatation with the patient under general anesthesia took an average of 1 .7 hr. The length of hospital stay was short, with a mean of 5.7 ± 4.5 days for all patients. Eleven patients who did not experience any complications had a shorter hospital stay (mean, 3.6 days; range, 1 -6 days) than did three patients who had complications (mean, 1 3.7 days; range, 1 3-1 4 days).
Fig. 1.-cholangiograms of left-sided percutaneous biliary stricture dilatation (PBSD) in a 50-year-old man who had elevated alkaline phosphatase level and episodes of recurrent cholangitis. Patient had a choledochoduodenostomy 10 years caner for benign disease. General anesthesia permitted whole procedure, from transhepatic cholangiography to PBSD, to be performed in a single 2-hr period. A, Left-sided catheter injection shows dilated intrahepatic ducts and a slightly narrowed common bile duct over a length of 2 cm (arrows) at level of anastomosis. This patient was one of seven patients who had abnormal findings on a biliary perfusion test. B, Dilatation with a 12-mm balloon shows no waist at level of stricture after third 3-mm balloon inflation. Patient was discharged 2 days after dilatation
with a 10-French catheter stenting stricture. C, 2 weeks later, patient returned as an outpatient for catheter removed, and patient remains asymptomatic 3 years later.
removal.
Catheter
injection
shows
a widely
patent
anastomosis
(arrows).
Catheter was
ONE-SESSION
AJA:157, December 1991
PERCUTANEOUS
Downloaded from www.ajronline.org by 117.245.43.132 on 10/06/15 from IP address 117.245.43.132. Copyright ARRS. For personal use only; all rights reserved
Complications included cholangitis in one patient, liver hematoma due to manipulation of the transhepatic track in another, and the development of a hepatic pseudoaneurysm in a third patient. Both the liver hematoma and the cholangitis resolved with conservative therapy and antibiotics, respectively. The hepatic pseudoaneurysm was treated with transcatheter embolization because of continued bleeding. To date, 1 3 of 1 4 patients remain free of symptoms with normal results in liver function tests. In two of these 13 patients, liver function test results showed transient elevations 2 and 3 years after PBSD. However, findings on repeated transhepatic cholangiography and quantitative perfusion studies were normal. A stricture recurred in one patient, who initially had an iatrogenic stricture, 1 .5 years after dilatation. The latter patient underwent further PBSD under general anesthesia and is now free of symptoms (1 2 months after dilatation). Internal-external stenting catheters remained in situ for an average of 1 0 days after dilatation (range, 6-21 days). Most patients returned as outpatients for cholangiography through the indwelling catheter, followed by catheter removal. No residual stricture was seen in any patient at this time, as compared with radiographs taken before dilatation. In patients who had longer hospital stays, the stenting catheters were removed before discharge, again after findings on cholangiography were normal. Quantitative manometric pressure studies were performed in seven patients before and after dilatation. Resting biliary pressure recordings before dilatation were abnormal in seven patients (mean, 26 cm saline; normal,
1263
Percutaneous Dilatation of Benign Biliary Strictures: Single-Session Therapy
Michael J. Lee1 Peter R. Mueller Sanjay Saini Peter F. Hahn Steven
L. Dawson
with General
Anesthesia
Percutaneous biliary patients that presently
stricture dilatation (PBSD) is an uncomfortable procedure for requires multiple dilatation sessions spread over many days. We evaluated the use of general anesthesia to enable PBSD to be performed in a single sitting in 14 patients with benign biliary strictures (11 anastomotic and three iatrogenlc strictures). Four patients had multiple strictures, and the other 10 had a single stricture. Strictures were documented by transhepatic cholangiography (11 patients) or T-tube cholangiography (three); quantitative biliary perfusion studies were additionally performed In seven cases. Dilatation was performed transhepatically in 1 1 patients and via a T-tube track in three. Balloons ranged from 8 to 12 mm in diameter and were manually inflated for 3 mm with an average of five Inflations per stricture. Stenting catheters were left across the strictured areas in all patients for 6-21 days (mean, 10 days) before
removal. further
The mean duration
of hospital
stay for all patients
was 5.7 days, which
could
into means of 3.6 days (range, 1-6 days) for 11 patients without complications and 13.7 days (range, 13-14 days) for three patients who had complicatons. Complications included cholangitis; liver hematoma (which resolved with censorvative therapy in both cases); and pseudoaneurysm of the hepatic artery, which necessitated angiographic embolization. PBSD achieved long-term patency in 13 (93%) of 14
patients
be divided
with a follow-up
period of 2.0 to 5.5 years (mean, 3.2 years).
A
stricture
recurred
in one patient 1.5 years after dilatation. We conclude that PBSD with the patient under general anesthesia can be performed in a single visit to the radiology department with excellent long-term patency rates, a shorter hospital stay, and a pain-free procedure for the patient. AJR 157:1263-1266,
Received May 30, 1991; accepted July26, 1991.
after revision
I All authors: Department of Radiology, Massechusetts General Hosptal and Harvard Medical School, 32 Fruit St., Boston, MA 021 14. Address
reprint
requests
to P. R. Mueller.
0361-803X/91/1576-1263 © Amencan Roentgen
Ray Society
December
1991
Many previous reports have emphasized the importance of percutaneous biliary dilatation as an effective alternative to surgical management of benign biliary strictures [1 -7]. Complications of this procedure are usually minimal, and the main complications of sepsis and bleeding are easily controlled. However, pain during the procedure, especially at the time of balloon inflation, can be severe and has remained problematic. Because of associated pain, biliary dilatation is often performed in several sessions, usually spread over 1 0 to 1 4 days. This necessarily increases the duration of hospital stay and absence from employment for most patients. Various solutions to the problem of pain during dilatation have been proposed and include (1) wide local infiltration with lidocaine or bupivacaine coupled with the liberal use of IV narcotics and sedatives, (2) direct installation of lidocaine or bupivacaine into the biliary tree [1 8], or (3) administration of general anesthesia, if required. We used to perform biliary dilatation in at least three sessions during a 5- to 8day period and employed a combination of local anesthesia and IV sedatives and narcotics [3]. However, in the past 5 years we have used general anesthesia for control of pain. An added benefit of this approach is the freedom to perform the entire procedure from percutaneous transhepatic biliary drainage to biliary dilatation ,
LEE
1264
in one session. We report here our results and the complications we encountered in using this approach in 1 4 patients.
Materials
and Methods
Downloaded from www.ajronline.org by 117.245.43.132 on 10/06/15 from IP address 117.245.43.132. Copyright ARRS. For personal use only; all rights reserved
We retrospectively percutaneous
of benign
biliary
strictures
in the
last
5 years.
Fourteen patients (eight male, six female; age range, 1 2-77 years; mean age, 44 years) had percutaneous biliary stricture dilatation (PBSD) under general anesthesia. The cause of the biliary strictures was previous surgery for benign disease with anastomotic strictures (choledochojejunostomy, hepaticojejunostomy) in 1 1 patients, and iatrogenic
surgical
trauma
AJR:157,
In all cases,
during
cholecystectomy
in three
patients.
had
cholangiography. Alkaline phosphatase measured in all patients before dilatation, to be elevated
in eight. Alkaline
phosphatase
a stricture
seen
at T-tube
and bilirubin levels were and the levels were found and bilirubin
levels were
elevated in the remaining six patients during episodes of cholangitis, but had returned to normal before PBSD. Sonography or CT was performed in all patients before dilatation and revealed mildly dilated biliary ducts in seven patients and normal nondilated ducts in the remaining
seven.
The
presence
of a stricture
was
documented
biliary
obstruction
before
dilatation
in the
first
seven
the
patient
under
to seven). Ten- to 1 2-French stenting the strictured areas in all patients after
The end point for successful in all patients
by the
dilatation
disappearance
was established
of a balloon
waist
qualitatively
during
so that the strictured
duct returned to the size of the adjacent
duct.
the end point
Quantitatively,
by recording
of dilatation
biliary pressures
was
inflation
normal
established
in
after the procedure.
Long-term patency was determined of liver function tests in all patients
by clinical follow-up and results for a mean of 3.2 ± 1 .1 years
(range,
physical
function
2.0-5.5 tests
years). were
Repeated
done,
sepsis were documented. cholangiography
and
episodes
Additionally,
was repeated
to assess
examination
of cholangitis,
in two patients
and liver jaundice,
or
transhepatic
patency.
in all
patients by either transhepatic cholangiography (1 1 patients) or Ttube cholangiography (three patients). Provocative perfusion studies were used to make quantitative manometric determinations of functional
with
from gaining access to the biliary tree (transhe-
per stricture (range, three catheters were left across
seven patients
patients
performed
inflated for 3 mm during each inflation, with an average of five inflations
without
three
was
track) to stricture dilatation, was done in all under general anesthesia (Fig. 1). Biliary strictures were dilated by using techniques previously described [3]. Balloons varied between 8 and 12 mm in diameter and were reinforced to allow high inflation pressures. All balloons were manually
dilatation.
and
dilatation
1991
patically or via a T-tube cases with the patient
Four patients had two strictures each while the rest had one stricture each. Twelve strictures were located in the common bile duct, and six were in the intrahepatic right or left main ducts. No patients with scierosing cholangitis were treated during this period. Eleven patients had recurrent episodes of cholangitis with or jaundice,
biliary
December
general anesthesia. The transhepatic approach was used in 1 1 patients and a T-tube track was used in three patients. All strictures were between 1 and 5 mm in diameter and less than 2 cm in length.
The entire procedure,
reviewed the records of all patients referred for
dilatation
ET AL.
patients.
Biliary pressures were measured and perfusion tests performed as described by previous investigators [9]. Quantitative pressure studies were not done in the remaining seven patients, because clinical and radiologic data convincingly proved the presence of significant biliary strictures.
Results PBSD from initial transhepatic cholangiography to stricture dilatation with the patient under general anesthesia took an average of 1 .7 hr. The length of hospital stay was short, with a mean of 5.7 ± 4.5 days for all patients. Eleven patients who did not experience any complications had a shorter hospital stay (mean, 3.6 days; range, 1 -6 days) than did three patients who had complications (mean, 1 3.7 days; range, 1 3-1 4 days).
Fig. 1.-cholangiograms of left-sided percutaneous biliary stricture dilatation (PBSD) in a 50-year-old man who had elevated alkaline phosphatase level and episodes of recurrent cholangitis. Patient had a choledochoduodenostomy 10 years caner for benign disease. General anesthesia permitted whole procedure, from transhepatic cholangiography to PBSD, to be performed in a single 2-hr period. A, Left-sided catheter injection shows dilated intrahepatic ducts and a slightly narrowed common bile duct over a length of 2 cm (arrows) at level of anastomosis. This patient was one of seven patients who had abnormal findings on a biliary perfusion test. B, Dilatation with a 12-mm balloon shows no waist at level of stricture after third 3-mm balloon inflation. Patient was discharged 2 days after dilatation
with a 10-French catheter stenting stricture. C, 2 weeks later, patient returned as an outpatient for catheter removed, and patient remains asymptomatic 3 years later.
removal.
Catheter
injection
shows
a widely
patent
anastomosis
(arrows).
Catheter was
ONE-SESSION
AJA:157, December 1991
PERCUTANEOUS
Downloaded from www.ajronline.org by 117.245.43.132 on 10/06/15 from IP address 117.245.43.132. Copyright ARRS. For personal use only; all rights reserved
Complications included cholangitis in one patient, liver hematoma due to manipulation of the transhepatic track in another, and the development of a hepatic pseudoaneurysm in a third patient. Both the liver hematoma and the cholangitis resolved with conservative therapy and antibiotics, respectively. The hepatic pseudoaneurysm was treated with transcatheter embolization because of continued bleeding. To date, 1 3 of 1 4 patients remain free of symptoms with normal results in liver function tests. In two of these 13 patients, liver function test results showed transient elevations 2 and 3 years after PBSD. However, findings on repeated transhepatic cholangiography and quantitative perfusion studies were normal. A stricture recurred in one patient, who initially had an iatrogenic stricture, 1 .5 years after dilatation. The latter patient underwent further PBSD under general anesthesia and is now free of symptoms (1 2 months after dilatation). Internal-external stenting catheters remained in situ for an average of 1 0 days after dilatation (range, 6-21 days). Most patients returned as outpatients for cholangiography through the indwelling catheter, followed by catheter removal. No residual stricture was seen in any patient at this time, as compared with radiographs taken before dilatation. In patients who had longer hospital stays, the stenting catheters were removed before discharge, again after findings on cholangiography were normal. Quantitative manometric pressure studies were performed in seven patients before and after dilatation. Resting biliary pressure recordings before dilatation were abnormal in seven patients (mean, 26 cm saline; normal,
