Technical Notes
TECHNICAL NOTES Percutaneous Transhepatic Cholangiography Utilizing the Chiba University Needle 1 Raul Pereiras, Jr., M.D., Patrick White, M.D., Maurice Dusol, Jr., M.D., George Irvin, III, M.D., Duane Hutson, M.D., Bernard Lieberman, M.D., and Eugene R. Schiff, M.D. Percutaneous transhepatic cholangiography with the Chiba University needle has been performed in 42 patients with cholestasis. The examination was successful in 100 % of patients with dilated intrahepatic bile ducts and in 89 % of those with normal-size ducts. Complications were minimal. The results of this study suggest that PTC with the Chiba needle is superior to the current conventional methods. The patients with intrahepatic cholestasis, which often simulates extrahepatic biliary obstruction, were spared an unnecessary laparotomy. INDEX TERMS: Bile ducts, obstruction. Bile ducts, radiography. (Biliary system, percutaneous cholangiography 7 6]. 1226) • Cholangiography, technique
r
Radiology 121:219-221, October 1976
Percutaneous transhepatic cholangiography (PTC) is an extremely valuable tool in the differential diagnosis of cholestasis. Biochemical and histological studies frequently fail to differentiate hepatocellular from extrahepatic causes of cholestasis; thus visualization of the biliary tree becomes essential (1, 2). A new technique for percutaneous transhepatic cholangiography employing a thin flexible 23-gauge needle has been described by Okuda et al. (3). This technique has proved to be a safe and efficient method resulting in visualization of a high percentage of dilated as well as nondilated biliary trees. We will report our experience with this new technique which confirms the results of others (3, 4). METHODS Forty-two patients with cholestasls, initially of unknown etiOIOgy, were studied. All patients had a prothrombin time within 3 seconds of the control, a partial prothrombin time of less than 50 seconds and a platelet count of greater than 90,000. No sedation was used during the study period. After an overnight fast, the patients were prepared in a standard manner for PTe. Following adequate sterilization of the skin, the needle was introduced in a site slightly anterior to the midaxillary line and as high as possible, avoiding the right costophrenic angle. In patients with a small contracted liver, a point slightly posterior to the midaxillary line was selected. The needle was aimed at a lead landmark placed over the abdomen equidistant between the dome of the diaphragm and the duodenal bulb, which is outlined by air. With this approach one attempts to enter a duct slightly above the bifurcation of the right and left main hepatic ducts. The highest entry point below the costophrenic angle will avoid going through the gallbladder. The stylet was then removed and normal respirations permitted. Contrast material (Renografin 60 %) was injected via a polyethylene tube attached to the needle which was slowly withdrawn under fluoroscopic monitoring. If a nondilated biliary tree was entered, several quick exposures were taken as 10-15 ml of contrast material was injected. Enough contrast media was then injected to fill the biliary tree and gallbladder, and the needle removed. If a dilated biliary system was encountered, 20-50 ml of bile was withdrawn and then similar amounts of contrast material injected. Aspiration
219
Fig. 1. Normal biliary tree in patient with intrahepatic cholestasis secondary to alcoholic hepatitis. (GB = gallbladder; CD = common duet.)
of bile alternating with the injection of contrast media was then repeatedly performed until there was complete filling of the biliary tree without over-distension. After multiple films were obtained at all possible projections, the ducts were completely decompressed, the needle removed, and the entry point covered with a band aid. Injection of contrast material into blood vessels was easily recognized by the direction of the flow, and its rapid disappearance. Liver lymphatics were differentiated from normal ducts by their tortuosity, increased number, and drainage toward the midline and into the cisterna chyli. If no biliary radicle could be entered after seven passes of the needle, a percutaneous biopsy was performed. Important features to be emphasized in performing this technique are: (a) Continued injection of contrast material during withdrawal of the needle (3-6). (b) Aspiration of bile alternating with injection of contrast material to prevent over-distension in dilated ducts (6). (c) Complete decompression of dilated ducts prior to the removal of the needle (6, 7). (d) The right flank approach is superior to the anterior sub-
220
TECHNICAL NOTES
Table I:
October 1976
Hepatobiliary Disease with Biliary Tract Distension
Disease Entity Cholecystitis & choledocholithiasis Primary bile duct carcinoma Pancreatic carcinoma Chronic pancreatitis Metastases to porta hepatis Dilated choledochus of unknown etiology Total
Biliary Tree Visualization Per Cent Yes No Patients
-
7
7
a
100
2 9 4
2 9 4
a a a a a a
100 100 100
1
24
-
1
24
Without Biliary Tract Distension Acute alcoholic liver disease without 4 4 cirrhosis a Acute alcoholic liver disease with 3 a cirrhosis 3 Primary biliary a 1 cirrhosis 1 a 1 Viral hepatitis 1 Liver cell carcinoma with postnecrotic 1 2 cirrhosis Benign postoperative cholestasis 0 Drug-induced 1 1 cholestasis 2 Histiocytic medullary retic ulosis 1 1 0 a Actinomycosis 1 1 Acute cholecystitis 0 2 2 -
Total
Fig.2. TheChiba University needle alongside the standard sheathed needle.
costal approach because it is less likely to lead to bile leakage into the peritoneal cavity (3). (e) Prophylactic antibiotic therapy (8). RESULTS Forty-two patients were studied. Successful visualization of the biliary tree was accomplished in 40 patients (95 % ) with a wide variety of biliary tract diseases (Fig. 1). Group A: dilated biliary tree-24 patients. Localization of the obstruction was accomplished in all 24 patients with a success rate of 100 % (TABLE I). Diagnosis was subsequently confirmed at surgery or autopsy in all cases except 2. GroupB: nondi/atedbiliary tree. The diagnosis of intrahepatic cholestasis was made in 16 of 18 patients by the presence of
18
16
-
2
100
-100 100
100 100 100 100 50 100 50 100 100 100 89%
a normal intra- and extrahepatic biliary tree for a success rate of 89 %. The diagnosis of intrahepatic disease was subsequently confirmed by liver biopsy or autopsy in all cases. Because of the reported safety of this procedure the patients were not routinely prepared for possible surgery following this study (9). There was no mortality in the entire series and no patients required an early operation. One patient with alcoholic hepatitis developed mild upper quadrant discomfort for several hours following the study with no evidence of peritonitis, fever or chills. One patient with a dilated biliary tree from carcinoma of the head of the pancreas suffered chills and fever immediately following the procedure which lasted for four hours and cleared spontaneously. Blood cultures were negative. In no instance was bile peritonitis or hemorrhage encountered. The use of a sharp-point, thin-gauge, flexible needle such as the Chiba University needle 2 (Fig. 2) reduces the incidence of bile leakage and permits injection of normal-size ducts in a high percentage of patients (3, 4, 6, 9). Visualization of the entire biliary tree was accomplished in 95 % of all the patients we studied: 100 % of those with dilated trees and 89 % of those with nondilated trees. Our figures confirm the published results of Okuda et al.: 100 % and 67.5 % success rate for dilated and nondilated biliary trees, respectively, and Redeker et al.: 100% and 60%, respectively (3,4). Recently, Okuda has presented the results of over 1,000 examinations in which the success rate for nondilated biliary systems is greater than 80 % (9). These results indicate that failure to visualize the biliary radicles with the Chiba needle virtually rules out extrahepatic ob-
Vol. 121
TECHNICAL NOTES
struction and the remarkably low morbidity makes it an extremely safe procedure. The need for scheduling the patient for possible surgical intervention within 24 hours of the procedure is no longer mandatory prior to the study period. The technique is easy to learn, safe, and requires less than 30 minutes. This modified form of PTC is the procedure of choice in resolving the differential diagnosis of obstructive jaundice. We feel that the Chiba needle will replace the traditional sheathed needle as the needle of choice for PTC. ACKNOWLEDGMENT: The authors wish to thank Mr. Arthur Hertz for his assistance in facilitating the study.
REFERENCES 1. Hines C Jr, Ferrante WA, Davis WD Jr, et al: Percutaneous transhepatic cholangiography. Experience with 102 procedures. Am J Dig Dis 17:868-874, Oct 1972 2. ShaldonS, Barber KM, Young WB: Percutaneoustranshepatic cholangiography. A modified technique. Gastroenterology 42:371-379, Apr 1962 3. Okuda K, Tanikawa K, Emura T, et al: Non-surgical percutaneous transhepatic cholangiography: diagnostic significance in medical problems of the liver. Am J Dig Dis 19:21-36, Jan 1974 4. Redeker AG, Karvountzis 00, Richman RH,et al: Percutaneous
221
Technical Notes
transhepatic cholangiography. An improved technique. JAMA 231: 386-387,27 Jan 1975 5. Arner 0, Hagberg S, Seldinger SI: Percutaneoustranshepatic cholangiography: puncture of dilated and nondllated bile ducts under roentgen television control. Surgery 52:561-571, Oct 1962 6. Herba MJ, Kiss J: Percutaneoustranshepatic cholangiography experience with 106 examinations. J Can Assoc RadioI22:22-29, Mar 1971 7. Plecha FR, Hughes CW, Smith ML, et al: Percutaneous transhepatic cholangiography. Arch Surg (Chicago) 92:672-676, May 1966 8. Flemma RJ, Schauble JF, Gardner CE Jr, et al: Percutaneous transhepatic cholangiography in the differential diagnosis of jaundice. Surg Gynecol Obstet 116:559-568, May 1963 9. Okuda et al: Unpublisheddata presented at the meeting of the American Association for the Study of Liver Disease, San Antonio, Texas, May 1975
1 From the Departmentof Medicine,Radiology and Surgery, Veterans Administration Hospital, Miami, Fla. (For reprints, write to Eugene R. Schiff, M.D., Chief, Hepatology Section, Veterans Administration Hospital, 1201 N.W. 16th Street, Miami, Fla. 33125.) Revised manuscript accepted for publication in March 1976. 2 For information, write to Harold Leigh, JohannahMedical Services, 3774 Dunlop St., St. Paul, Minn. 55112. shan
Simple Construction of a 1~~Yb_ 1~~m Absorber for Peak Kilovoltage Calibration of a Diagnostic X-Ray Machine 1 Chuck T. Aoki, M.Sc. A simple method for constructing a 1~~Yb_1~~m absorber for calibration of peak kilovoltage of x-ray machines is reported, involving the measurement of the K-characteristic x ray of 1~~Yb_1~~m at 60 keV. INDEX TERMS:
Radiography, apparatus and equipment. Ytterbium, radioac-
tive Radiology 121:221-222, October 1976
During the routine calibration of diagnostic x-ray machines at our institution, we measure the K-characteristic x ray, or K-edge, of various elements (1) in order to check the peak kilovoltage. A simple method of constructing a primary absorber is measuring the K-edge of 1~6Yb-1~~m. In solution form, 1~6Yb is used in our nuclear medicine clinic for cisternography; it decays to the more stable 1~~m with an approximate half-life of 30 days. Unused 1~6Yb was therefore saved and set aside for 5 months or more, and the Yb-Tm solution was used for K-edge measurements. To construct the primary absorber, a piece of gauze (8.0 cm X 8.0 cm X 0.3 cm) was saturated with 2-3 rnt of the Yb-Tm solution and placed inside a thin plastic bag. The exposure rate at the surface of the absorber was measured to be less than 10 mR/hr. The absorber can be stored safely by placing it between two sheets of lead for radiation protection purposes. Although any radioactive 1nYb present in the absorber will eventually decay to stable 1~~m, it is recommended that prongs be used to handle the absorber during K-edge measurements. The K-edge of Yb-Tm was measured by Trew's method (2), using a Victoreen 666 survey meter
Fig. 1. Apparatus used for K-edge measurements. Directly beneath the x-ray tube is the Yb-Tm absorber. The radiation probe is surrounded by 3.0 mm of lead; a 0.25 mm sheet of lead is placed between the probe and absorber.
with a large-diameter background probe. The small amount of radioactive 1~gYb in the absorber does not hinder the measurements, since the x-ray exposures are on the order of
TECHNICAL NOTES Percutaneous Transhepatic Cholangiography Utilizing the Chiba University Needle 1 Raul Pereiras, Jr., M.D., Patrick White, M.D., Maurice Dusol, Jr., M.D., George Irvin, III, M.D., Duane Hutson, M.D., Bernard Lieberman, M.D., and Eugene R. Schiff, M.D. Percutaneous transhepatic cholangiography with the Chiba University needle has been performed in 42 patients with cholestasis. The examination was successful in 100 % of patients with dilated intrahepatic bile ducts and in 89 % of those with normal-size ducts. Complications were minimal. The results of this study suggest that PTC with the Chiba needle is superior to the current conventional methods. The patients with intrahepatic cholestasis, which often simulates extrahepatic biliary obstruction, were spared an unnecessary laparotomy. INDEX TERMS: Bile ducts, obstruction. Bile ducts, radiography. (Biliary system, percutaneous cholangiography 7 6]. 1226) • Cholangiography, technique
r
Radiology 121:219-221, October 1976
Percutaneous transhepatic cholangiography (PTC) is an extremely valuable tool in the differential diagnosis of cholestasis. Biochemical and histological studies frequently fail to differentiate hepatocellular from extrahepatic causes of cholestasis; thus visualization of the biliary tree becomes essential (1, 2). A new technique for percutaneous transhepatic cholangiography employing a thin flexible 23-gauge needle has been described by Okuda et al. (3). This technique has proved to be a safe and efficient method resulting in visualization of a high percentage of dilated as well as nondilated biliary trees. We will report our experience with this new technique which confirms the results of others (3, 4). METHODS Forty-two patients with cholestasls, initially of unknown etiOIOgy, were studied. All patients had a prothrombin time within 3 seconds of the control, a partial prothrombin time of less than 50 seconds and a platelet count of greater than 90,000. No sedation was used during the study period. After an overnight fast, the patients were prepared in a standard manner for PTe. Following adequate sterilization of the skin, the needle was introduced in a site slightly anterior to the midaxillary line and as high as possible, avoiding the right costophrenic angle. In patients with a small contracted liver, a point slightly posterior to the midaxillary line was selected. The needle was aimed at a lead landmark placed over the abdomen equidistant between the dome of the diaphragm and the duodenal bulb, which is outlined by air. With this approach one attempts to enter a duct slightly above the bifurcation of the right and left main hepatic ducts. The highest entry point below the costophrenic angle will avoid going through the gallbladder. The stylet was then removed and normal respirations permitted. Contrast material (Renografin 60 %) was injected via a polyethylene tube attached to the needle which was slowly withdrawn under fluoroscopic monitoring. If a nondilated biliary tree was entered, several quick exposures were taken as 10-15 ml of contrast material was injected. Enough contrast media was then injected to fill the biliary tree and gallbladder, and the needle removed. If a dilated biliary system was encountered, 20-50 ml of bile was withdrawn and then similar amounts of contrast material injected. Aspiration
219
Fig. 1. Normal biliary tree in patient with intrahepatic cholestasis secondary to alcoholic hepatitis. (GB = gallbladder; CD = common duet.)
of bile alternating with the injection of contrast media was then repeatedly performed until there was complete filling of the biliary tree without over-distension. After multiple films were obtained at all possible projections, the ducts were completely decompressed, the needle removed, and the entry point covered with a band aid. Injection of contrast material into blood vessels was easily recognized by the direction of the flow, and its rapid disappearance. Liver lymphatics were differentiated from normal ducts by their tortuosity, increased number, and drainage toward the midline and into the cisterna chyli. If no biliary radicle could be entered after seven passes of the needle, a percutaneous biopsy was performed. Important features to be emphasized in performing this technique are: (a) Continued injection of contrast material during withdrawal of the needle (3-6). (b) Aspiration of bile alternating with injection of contrast material to prevent over-distension in dilated ducts (6). (c) Complete decompression of dilated ducts prior to the removal of the needle (6, 7). (d) The right flank approach is superior to the anterior sub-
220
TECHNICAL NOTES
Table I:
October 1976
Hepatobiliary Disease with Biliary Tract Distension
Disease Entity Cholecystitis & choledocholithiasis Primary bile duct carcinoma Pancreatic carcinoma Chronic pancreatitis Metastases to porta hepatis Dilated choledochus of unknown etiology Total
Biliary Tree Visualization Per Cent Yes No Patients
-
7
7
a
100
2 9 4
2 9 4
a a a a a a
100 100 100
1
24
-
1
24
Without Biliary Tract Distension Acute alcoholic liver disease without 4 4 cirrhosis a Acute alcoholic liver disease with 3 a cirrhosis 3 Primary biliary a 1 cirrhosis 1 a 1 Viral hepatitis 1 Liver cell carcinoma with postnecrotic 1 2 cirrhosis Benign postoperative cholestasis 0 Drug-induced 1 1 cholestasis 2 Histiocytic medullary retic ulosis 1 1 0 a Actinomycosis 1 1 Acute cholecystitis 0 2 2 -
Total
Fig.2. TheChiba University needle alongside the standard sheathed needle.
costal approach because it is less likely to lead to bile leakage into the peritoneal cavity (3). (e) Prophylactic antibiotic therapy (8). RESULTS Forty-two patients were studied. Successful visualization of the biliary tree was accomplished in 40 patients (95 % ) with a wide variety of biliary tract diseases (Fig. 1). Group A: dilated biliary tree-24 patients. Localization of the obstruction was accomplished in all 24 patients with a success rate of 100 % (TABLE I). Diagnosis was subsequently confirmed at surgery or autopsy in all cases except 2. GroupB: nondi/atedbiliary tree. The diagnosis of intrahepatic cholestasis was made in 16 of 18 patients by the presence of
18
16
-
2
100
-100 100
100 100 100 100 50 100 50 100 100 100 89%
a normal intra- and extrahepatic biliary tree for a success rate of 89 %. The diagnosis of intrahepatic disease was subsequently confirmed by liver biopsy or autopsy in all cases. Because of the reported safety of this procedure the patients were not routinely prepared for possible surgery following this study (9). There was no mortality in the entire series and no patients required an early operation. One patient with alcoholic hepatitis developed mild upper quadrant discomfort for several hours following the study with no evidence of peritonitis, fever or chills. One patient with a dilated biliary tree from carcinoma of the head of the pancreas suffered chills and fever immediately following the procedure which lasted for four hours and cleared spontaneously. Blood cultures were negative. In no instance was bile peritonitis or hemorrhage encountered. The use of a sharp-point, thin-gauge, flexible needle such as the Chiba University needle 2 (Fig. 2) reduces the incidence of bile leakage and permits injection of normal-size ducts in a high percentage of patients (3, 4, 6, 9). Visualization of the entire biliary tree was accomplished in 95 % of all the patients we studied: 100 % of those with dilated trees and 89 % of those with nondilated trees. Our figures confirm the published results of Okuda et al.: 100 % and 67.5 % success rate for dilated and nondilated biliary trees, respectively, and Redeker et al.: 100% and 60%, respectively (3,4). Recently, Okuda has presented the results of over 1,000 examinations in which the success rate for nondilated biliary systems is greater than 80 % (9). These results indicate that failure to visualize the biliary radicles with the Chiba needle virtually rules out extrahepatic ob-
Vol. 121
TECHNICAL NOTES
struction and the remarkably low morbidity makes it an extremely safe procedure. The need for scheduling the patient for possible surgical intervention within 24 hours of the procedure is no longer mandatory prior to the study period. The technique is easy to learn, safe, and requires less than 30 minutes. This modified form of PTC is the procedure of choice in resolving the differential diagnosis of obstructive jaundice. We feel that the Chiba needle will replace the traditional sheathed needle as the needle of choice for PTC. ACKNOWLEDGMENT: The authors wish to thank Mr. Arthur Hertz for his assistance in facilitating the study.
REFERENCES 1. Hines C Jr, Ferrante WA, Davis WD Jr, et al: Percutaneous transhepatic cholangiography. Experience with 102 procedures. Am J Dig Dis 17:868-874, Oct 1972 2. ShaldonS, Barber KM, Young WB: Percutaneoustranshepatic cholangiography. A modified technique. Gastroenterology 42:371-379, Apr 1962 3. Okuda K, Tanikawa K, Emura T, et al: Non-surgical percutaneous transhepatic cholangiography: diagnostic significance in medical problems of the liver. Am J Dig Dis 19:21-36, Jan 1974 4. Redeker AG, Karvountzis 00, Richman RH,et al: Percutaneous
221
Technical Notes
transhepatic cholangiography. An improved technique. JAMA 231: 386-387,27 Jan 1975 5. Arner 0, Hagberg S, Seldinger SI: Percutaneoustranshepatic cholangiography: puncture of dilated and nondllated bile ducts under roentgen television control. Surgery 52:561-571, Oct 1962 6. Herba MJ, Kiss J: Percutaneoustranshepatic cholangiography experience with 106 examinations. J Can Assoc RadioI22:22-29, Mar 1971 7. Plecha FR, Hughes CW, Smith ML, et al: Percutaneous transhepatic cholangiography. Arch Surg (Chicago) 92:672-676, May 1966 8. Flemma RJ, Schauble JF, Gardner CE Jr, et al: Percutaneous transhepatic cholangiography in the differential diagnosis of jaundice. Surg Gynecol Obstet 116:559-568, May 1963 9. Okuda et al: Unpublisheddata presented at the meeting of the American Association for the Study of Liver Disease, San Antonio, Texas, May 1975
1 From the Departmentof Medicine,Radiology and Surgery, Veterans Administration Hospital, Miami, Fla. (For reprints, write to Eugene R. Schiff, M.D., Chief, Hepatology Section, Veterans Administration Hospital, 1201 N.W. 16th Street, Miami, Fla. 33125.) Revised manuscript accepted for publication in March 1976. 2 For information, write to Harold Leigh, JohannahMedical Services, 3774 Dunlop St., St. Paul, Minn. 55112. shan
Simple Construction of a 1~~Yb_ 1~~m Absorber for Peak Kilovoltage Calibration of a Diagnostic X-Ray Machine 1 Chuck T. Aoki, M.Sc. A simple method for constructing a 1~~Yb_1~~m absorber for calibration of peak kilovoltage of x-ray machines is reported, involving the measurement of the K-characteristic x ray of 1~~Yb_1~~m at 60 keV. INDEX TERMS:
Radiography, apparatus and equipment. Ytterbium, radioac-
tive Radiology 121:221-222, October 1976
During the routine calibration of diagnostic x-ray machines at our institution, we measure the K-characteristic x ray, or K-edge, of various elements (1) in order to check the peak kilovoltage. A simple method of constructing a primary absorber is measuring the K-edge of 1~6Yb-1~~m. In solution form, 1~6Yb is used in our nuclear medicine clinic for cisternography; it decays to the more stable 1~~m with an approximate half-life of 30 days. Unused 1~6Yb was therefore saved and set aside for 5 months or more, and the Yb-Tm solution was used for K-edge measurements. To construct the primary absorber, a piece of gauze (8.0 cm X 8.0 cm X 0.3 cm) was saturated with 2-3 rnt of the Yb-Tm solution and placed inside a thin plastic bag. The exposure rate at the surface of the absorber was measured to be less than 10 mR/hr. The absorber can be stored safely by placing it between two sheets of lead for radiation protection purposes. Although any radioactive 1nYb present in the absorber will eventually decay to stable 1~~m, it is recommended that prongs be used to handle the absorber during K-edge measurements. The K-edge of Yb-Tm was measured by Trew's method (2), using a Victoreen 666 survey meter
Fig. 1. Apparatus used for K-edge measurements. Directly beneath the x-ray tube is the Yb-Tm absorber. The radiation probe is surrounded by 3.0 mm of lead; a 0.25 mm sheet of lead is placed between the probe and absorber.
with a large-diameter background probe. The small amount of radioactive 1~gYb in the absorber does not hinder the measurements, since the x-ray exposures are on the order of
