1977, British Journal of Radiology, 50, 175-180

MARCH

1977

Percutaneous transhepatic cholangiography using the "Chiba"* needle—80 cases By S. Jain, M.B., M.R.C.P., R. G. Long, M.B., M.R.C.P., J. Scott, B.Sc, M.R.C.P., R. Dick, M.B., M.R.A.C.R., F.R.C.R., and Sheila Sherlock, M.D., F.R.C.P. The Royal Free Hospital, Department of Medicine, Hampstead, London NW3 2QG (Received August, 1976 and in revisedform November, 1976.)

ABSTRACT

Using the Chiba needle for percutaneous transhepatic cholangiography, bile ducts have been visualized radiographically in 80% of 80 patients with cholestatic jaundice. The success rate was 94.4% in the 54 patients with dilated bile ducts due to an extrahepatic bilary obstruction, and 50% of the 20 patients with undilated ducts. Four patients developed ascending cholangitis with septicaemia on the same day as the procedure, and early surgery after visualization of obstructed bile ducts is recommended. The technique was successful in three of five patients with sclerosing cholangitis. Percutaneous cholangiography using the Chiba needle is a convenient method of opacifying the biliary system in patients with severe large bile duct obstruction.

Improved techniques for the radiographic visualization of the biliary system allow better investigation of cholestatic jaundice, and operative surgery is no longer necessary for primary diagnosis. Endoscopic retrograde cholangiography (ERC) has a success rate of 74-94% in specialist centres (Cotton, 1972; Blumgart et al, 1972). It can, however, be a difficult and time-consuming technique, the endoscopes are costly, and only the lower margin of a tight lesion obstructing the biliary tract is shown. High dose intravenous infusion cholangiography may opacify the large bile ducts in moderately severe jaundice, but may fail to supply sufficient anatomical detail because of dilution of the contrast medium with bile (Scholz et al, 1975). Percutaneous transhepatic cholangiography (PTC) using the Chiba needle (Okuda et al, 1974) offers several advantages over the older anteriorly introduced sheathed needle where an aspirating technique is used. The lateral insertion enables the operator to inject contrast medium continuously while withdrawing the needle under fluoroscopic control, without exposing himself to excessive radiation. The flexibility of the needle enables the patient to breathe normally throughout the procedure without trauma to the liver or its capsule. Initial reports show that normal bile ducts are frequently cannulated, and even in the presence of complete biliary obstruction, immediate surgery may not be necessary (Okuda et al., 1974; •Chiba needles manufactured by Messrs. V, J. Millard, 36 Highgate Hill, London, N19.

A randomized trial to compare ERC with PTC for bile duct visualization showed an overall success rate using the Chiba needle of 56.8% in 44 examinations. The success rate was 95% in extrahepatic cholestasis and only 25% for patients who were found to have intrahepatic cholestasis (Elias et al., 1976). Following this trial, PTC has been performed on 80 additional patients with cholestatic jaundice. The indication for the procedure was to confirm or exclude large bile duct obstruction and in each case oral or intravenous cholangiography was impossible because of deep jaundice, or had previously given unsatisfactory results. PATIENTS AND METHODS

All 80 patients had cholestatic jaundice. Eleven were known to have primary biliary cirrhosis, but deepening jaundice or right upper quadrant pain made the presence of common bile duct stones possible, as cholelithiasis is common in primary biliary cirrhosis (Summerfield et al., 1976). The other 69 patients were considered to have probable large duct obstruction requiring investigation (Table I). The Chiba needle was used as previously described (Okuda et al, 1974; Elias et al, 1976). Antibiotic therapy was started between 1 and 24 hours before the procedure, which was performed only if the prothrombin time was no more than three seconds prolonged over control. Intravenous diazepam was used as premedication, and local anaesthesia was achieved with lignocaine 1%, in the 7th, 8th or 9th intercostal space in the mid-axilary line. The intercostal space was chosen by maximal dullness to percussion and the position of the liver by preliminary X-ray of the abdomen when the patient was prepared in the supine position. The highly flexible Chiba needle was then introduced into the liver parallel to the table top, and perpendicular to the spine, until judged to have reached the depth of the right border of the spine. After removal of the stylette, contrast medium (Hypaque 45 or Conray 280) was injected continuously while withdrawing the needle under fluoroscopic vision. Structures

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50, No. 591 S. Jain, R. G. Long, J. Scott, R. Dick and Sheila Sherlock TABLE I PATIENTS STUDIED

Number Success

Fail

Total

80

64

Stone in CBD

20

16

4*

Post-surgical stricture

12

12

0

Ca pancreas

11

9

2

PBC—no obstruction

10

5

5

Ca bile duct

6

6

0

Sclerosing cholangitis

5

3

2

Secondary carcinoma

4

4

0

Cholestatic hepatitis

3

2

1

Chronic pancreatitis

2

2

0

Ca ampulla of Vater

2

2

0

Ca gall-bladder

2

2

0

PBC with stone in CBD

1

1

0

Empyema of gall-bladder

1

0

1

Biliary atresia

1

0

1

16

Fig. 2 A peripheral branch of a portal vein outlined by continuous injection of contrast medium.

*Procedure abandoned in one patient after two insertions of the needle PBC—Primary Biliary Cirrhosis.

imr. Fig.t. Parenchymatous deposit (A) and hepatic vein (B). There is barium in the ascending colon.

FIG. 3. Lymphatics from parenchymatous deposit to gastrohepatic ligament and coeliac lymph node.

MARCH

1977

Percutaneous transhepatic cholangiography using the "Chiba" needle

other than bile ducts were frequently opacified. Injection into liver parenchyma resulted in a localized deposit of contrast which was slow to clear (Fig. 1). Portal and hepatic veins were recognizable by the direction of flow, and rapid disappearance of contrast medium when injection was stopped (Figs. 1 and 2). Entry of the needle into a hepatic vein radicle frequently led to persistent filling of that vein through the tract made when the needle was withdrawn and more contrast injected. Lymphatics could be filled, usually after injection of contrast into hepatic parenchyma (Fig. 3). These were recognized by their characteristic size, multiplicity and direction of flow, coursing with the portal tracts to the hilum of the liver, then in the gastrohepatic ligament to the coeliac lymph nodes overlying the region of 12th thoracic vertebra (Goldberg et al., 1975). Radiopaque contrast took five to ten minutes to be cleared

from the lymphatic channels. When contrast medium entered a bile duct it flowed in both directions, cleared slowly, and further injection usually filled several adjacent radicles, particularly if outflow into the duodenum was obstructed. If bile ducts were not entered during the first withdrawal of the needle, it was re-inserted up to five times with some change in its direction each time, before the examination was abandoned. The procedure caused minimum discomfort to the patient unless contrast medium was inadvertently injected under the capsule of the liver. After injection of contrast medium into obstructed and dilated bile ducts, the picture of high duct obstruction was frequently seen (Fig. 5). In this circumstance, it is essential to tilt the patient upright and take a further film after 30 minutes, as this may be the early picture of low duct obstruction, with slow filling of the common bile duct with diluted

FIG. 4. Sclerosing cholangitis with narrowed segments of bile ducts (c). Gall bladder is filled (D) and contrast medium flows into duodenum unobstructed(E).

FIG. 5. Early picture shows dilated intra-hepatic bile ducts with suspected block at the hilum (F).

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50, No. 59t S. Jain, R. G. Long, J. Scott, R. Dick and Sheila Sherlock TABLE II NUMBER OF INSERTIONS BEFORE SUCCESS IN PATIENTS WITH DILATED AND UN-DILATED BILE DUCTS

Number of insertions

Dilated ducts—53 patients Undilated ducts—27 patients

1

2

3

4

5

6

Not recorded

21

14

4

2

3

3

3

3

3

2

3

2

0

2

2

13

FIG. 6. Same patient as Fig.5, 30 minutes later common bile duct is opacified and dilated (G). A stone is blocking the ampulla of Vater (H) and there is a stone in the gall-bladder (j).

contrast medium. Figure 6 shows the same patient after this procedure was employed, the later film showing a stone wedged in the ampulla of Vater.

Unsuccessful

obstruction to be due to stones low in the common bile duct. In the 16 unsuccessful attempts at PTC, the final diagnosis (Table I) was subsequently established by ERC (10 cases), surgery (4 cases) or liver biopsy (2 cases). In one of these patients the examination was abandoned after two insertions of the needle because of severe pain and hypotension which were adverse reactions to the injected medium. Bile ducts were more frequently visualized if they were dilated. When the appearance of the bile ducts was considered, either by PTC in the successful cases, or ERC or surgery with operative cholangiography in the remainder, dilatation of at least some part of the large bile duct system was apparent in 54 of the 80 patients. The 26 patients with undilated ducts were made up of 15 with intrahepatic cholestasis and 11 with extrahepatic cholestasis. The success rate of PTC was 51 out of 54 (94.4%) for patients with dilated ducts, and 13 out of 26 (50%) for patients with no dilated bile ducts. The number of insertions of the needle needed to achieve bile duct visualization was recorded in 59 of the 64 successful examinations. In the presence of dilated ducts, success was usual after the first or second insertion (Table II). If there was no dilation of the bile ducts the distribution of successful attempts was more even. Success at the sixth pass of the needle suggests that even more attempts would improve the rate of bile duct visualization whether or not they are dilated.

RESULTS

Bile duct visualization was achieved in 64 of the 80 patients (Table I), an overall success rate of 80%. The investigation was considered to be satisfactory when it showed either unobstructed bile ducts, or the anatomical site of an obstruction which was later confirmed by surgery. In one of the 64 cases where bile ducts were entered, PTC showed the picture of a high obstruction with no contrast medium entering the common bile duct despite tilting the patient and waiting for 30 minutes, and a malignant lesion was suspected. Subsequent surgery however showed the

COMPLICATIONS

Four patients developed cholangitis within half to six hours after PTC despite prophylactic antibiotic therapy. Two had stones in the common bile duct, one sclerosing cholangitis with a common bile duct structure, and one had a surgical stricture. All four patients has a history of previous cholangitis, but a similar history was obtained in 22 of the 64 patients where ducts were visualized. The incidence of cholangitis was therefore 4 out of 64 (6.25%) for successful procedures, and 4 out of 22 (18.2%) for

178

MARCH

1977

Percutaneous transhepatic cholangiography using the "Chiba" needle TABLE III COMPARISON OF SUCCESS RATES AND COMPLICATIONS IN FOUR CHIBA NEEDLE SERIES AND ONE USING SHEATHED NEEDLE

Total number

Overall success rate, 0/

/o

Surgical/ Extrahepatic, total number

Success rate, O'

/o

Medical/ Intrahepatic, total number

Success rate, O'

/o

Complications, O '

/o

George et al.

137 (sheathed)

70.8

112

83.9

25

12

Okuda et al.

314 (Chiba)

85.3

234

91.5

80

67.5

7.6

Redeker et al.

40 (Chiba)

80

20

100

20

60

5

Elias et al.

44 (Chiba)

56.8

20

95

24

25

6.8

Jain et al.

80 (Chiba)

80

60

90

15

46.7

6.25

those with previous cholangitis which was frequently associated with common bile duct stones and surgical strictures. When the procedure abandoned because of adverse reactions to the contrast medium was included, the total incidence of significant complications was 5 out of 80, also 6.25%. DISCUSSION

Comparison of our results with previous series using the Chiba needle or the sheathed needle is complicated by differences in the classification of the patients studied. Okuda et al. (1974) divided their patients into those with surgical and non-surgical hepatobiliary disease, and Redeker et al. (1975) into those with proved biliary tract obstruction, and those with undilated, unobstructed bile ducts. Elias et al. (1976) called the groups extra- and intrahepatic cholestasis. To divide the patients in this series into the two comparable groups, surgical or extrahepatic cholestasis, and non-surgical or intrahepatic cholestasis, the five patients with sclerosing cholangitis must be excluded as they do not readily fall into either group. Bile ducts were successfully visualized in three of these patients (Fig. 4). The cholestatic jaundice of chronic pancreatitis (Warshaw et al., 1976; Scott et al., 1976) is included in the surgical extrahepatic group. Comparison now shows that the improved rate of duct visualization achieved in this current study (80%) compared with that previously reported from this unit is due to better results in the non-surgical intrahepatic cholestasis group. The success rate was 54 out of 60 (90%) in surgical extrahepatic jaundice and 7 out of 15 (46.7%) in non-surgical intrahepatic cholestasis (Table III). This is still a lower success rate than the

Not recorded

Okuda and Redeker series, but may reflect practice and improvement in our technique. The other major difference is that we do not have a 100 % success rate for patients with biliary tract obstruction, and this diagnosis cannot be excluded with certainty by failing to opacify bile ducts. The incidence of significant complications is similar to previous series (Table III), and occurred only in patients with lesions obstructing the extrahepatic biliary system. Contrary to previous recommendations (Okuda et al., 1974; Redeker et al., 1975) this series confirms that on finding an obstructing lesion on PTC, our practice of proceeding to operative surgery on the same day as the investigation is correct (Elias et al., 1976), and the delay of up to six hours, during which time four of our patients developed cholangitis, would appear to be too long. The incidence of cholangitis after the procedure would certainly be reduced if, after entry into dilated bile ducts is confirmed by injection of a small amount of contrast medium under fluoroscopy, the biliary system could be decompressed by aspiration of bile. This has not been possible in our hands probably because of the internal diameter of the needle used is slightly smaller than that of Okuda et al. (0.5 mm), and the bile is too viscous to be aspirated through the needle. This is possible with the sheathed needle where infected bile may be drained preoperatively in a severely ill patient with cholangitis, biliary tract obstruction and septicaemia, and is an advantage of that technique. Controlled comparison of the two procedures has not been made, but in one review the success rate in 1629 procedures using the sheathed needle was 74% (Hines et al., 1972), which is comparable to the results in this series. When patients

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S. Jain, R. G. Long, J. Scott, R. Dick and Sheila Sherlock with intrahepatic cholestasis were analysed separately the success rate with the sheathed needle was only 12% (George etal, 1965). The principal advantages of the Chiba needle technique are that it is a simple and relatively atraumatic procedure which is usually very well tolerated by the patient, and which need be followed by operative surgery only if biliary obstruction is found. The overall success rate for the procedure is slightly higher than that of the sheathed needle technique, and much higher for patients with intrahapetic cholestasis. ADDENDUM

Since this paper was submitted we have used a 22 gauge needle (external diameter 0.71 mm, internal diameter 0.42 mm) instead of the 23 gauge needle (external diameter 0.64 mm, internal diameter 0.33 mm) used in this paper. With this larger needle we can aspirate bile and have had no septicaemic complications. It is possible that aspiration of bile may reduce the incidence of cholangitis and septicaemia seen in the above series.

FIELD, J. A., DICK, R., and SHERLOCK, S., 1976. A

randomised trial of percutaneous transhepatic cholangiography with the Chiba needle versus endoscopic retrograde cholangiography for bile duct visualisation in jaundice. Gastroenterology, 71, 439-443. GEORGE, P., YOUNG, W. B., WALKER, J. G., and SHERLOCK,

S., 1965. The value of percutaneous cholangiography. British Journal of Surgery, 52, 779-783. GOLDBERG, H. I., DODDS, W. J., LAWSON, T. L., STEWART,

E. T. and Moss, A. A., 1975. Hepatic lymphatics demonstrated by percutaneous transhepatic cholangiography. American Journal of Roentgenology and Radium Therapv, 723,415-419. HINES, C. H., FERRANTE, W. A., DAVIS, W. D., and TUTTON,

R. A., 1972. Percutaneous transhepatic cholangiography, experience with 100 procedures. Digestive Diseases, 17, 868-874. 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., and MATSUURA, T., 1974. Nonsurgical,

percutaneous transhepatic cholangiography—diagnostic significance in medical problems of the liver. Digestive Diseases, 79,21-26. REDEKER, A. G., KARVOUNTZIS, G. G., RICHMAN, R. H., and

HORISANA, M., 1975. Percutaneous transhepatic cholangiography. Journal of American Medical Association, 231. 386-387. SCHOLZ, F. J., JOHNSTON, D. D., and WISE, R. E., 1975. In-

travenous cholangiography, optimum dose and methodology. Radiology, 114, 51 3-518. SCOTT, J. SUMMERFIELD, J. A., ELIAS, E., DICK, R., and

SHERLOCK, S., 1976. Chronic pancreatis: a cause of cholestasis. Gastroenterology, 70, A-135/993.

REFERENCES BLUMGART, L. H., SALMON, P., COTTON, P. B., DAVIES, G. T., BURWOOD, R., BEALES, J. S. M., LAWRIE, B.,

SUMMERFIELD, J. A., ELIAS, E., HUNGERFORD, G. D., DICK,

R., and SHERLOCK, S., 1976. The biliary system in primary biliary cirrhosis. Gastroenterology, 70, 240-243.

SKIRVING, A., and READ, A. E., 1972. Endoscopy and retro-

grade choledochopancreatography in the diagnosis of the jaundiced patient. Lancet, 2,1269-1272. COTTON, P. B., 1972. Cannulation of the papilla of Vater by endoscopy and retrograde cholangiopancreatography (ERCP). Gut, 13,1014-1025.

WARSHAW, A. L., SCHAPIN, R. H., FERRUCII, J. T., and

ELIAS, E., HAMLYN, A. N., JAIN, S., LONG, R. G., SUMMER-

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GALDABINI, J. J., 1976. Persistent obstructive jaundice, cholangitis and biliary cirrhosis due to common bile duct stenosis in chronic pancreatitis. Gastroenterology, 70, 562-567.

Percutaneous transhepatic cholangiography using the "Chiba" needle--80 cases.

1977, British Journal of Radiology, 50, 175-180 MARCH 1977 Percutaneous transhepatic cholangiography using the "Chiba"* needle—80 cases By S. Jain,...
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