|Year : 2020 | Volume
| Issue : 4 | Page : 103-107
Left versus right-sided percutaneous transhepatic biliary drainage in relief of malignant obstruction
Musaib Ahmad Dar1, Naseer Choh2, Suhail Rafiq1, Feroze Shaheen2, Sadaf Ali3, Irfan Robbani2
1 Department of Radiodiagnosis and Imaging, GMC, Srinagar, Jammu and Kashmir, India
2 Department of Radiodiagnosis and Imaging, SKIMS, Srinagar, Jammu and Kashmir, India
3 Department of Surgical Gastroenterology, SKIMS, Srinagar, Jammu and Kashmir, India
|Date of Submission||22-Apr-2020|
|Date of Decision||28-Apr-2020|
|Date of Acceptance||06-May-2020|
|Date of Web Publication||9-Oct-2020|
Dr. Suhail Rafiq
Department of Radiodiagnosis and Imaging, GMC, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Biliary tree obstruction and consequent jaundice occur in 70%–90% of these patients and have important consequences mainly for the patient's quality of life, morbidity, and overall mortality. Percutaneous transhepatic biliary drainage (PTBD) is an excellent palliative procedure to drain the bile ducts in malignant obstruction. We compared left- and right-sided approach in relief of malignant obstruction. The most common causes of malignant biliary obstruction (MBO) include pancreatic adenocarcinoma, hilar cholangiocarcinoma, ampullary/duodenal adenocarcinoma, gallbladder adenocarcinoma, lymphoma, and compressive metastatic peri-portal lymph node Materials and Methods: This study was a prospective, hospital-based study performed for 2 years from 2016 to 2018. PTBD was performed either through right in 16 patients or left approach in 15 patients. Two approaches were compared in terms of clinical and technological success, changes in laboratory data, internalization and survival. Results: (1) Rate of technological success was 100%. (2) There was a significant reduction in bilirubin, alanine transaminase (ALT), and alkaline phosphatase (ALP) levels after the procedure in both the approaches, but the decrease was more in the right-sided approach. Only the decrease in bilirubin levels was statistically significant. The decrease in albumin was attributed to the progression of the disease. (3) Clinical success was seen in 93.33% and 93.75% in left- and right-sided approach. (4) Internalization was done in 86.67% patients in the left-lobe approach, while as in right-lobe approach, it was done in 93.75% patients. Conclusion: PTBD causes a significant reduction in the bilirubin level, irrespective of the amount of liver drained or the type of drainage (external/internal). In our study, the reduction in bilirubin, ALT and ALP was more in the right-lobe approach. However, only reductions in levels of bilirubin were statistically significant.
Keywords: Alkaline phosphatase, alanine transaminase, bilirubin, percutaneous transhepatic biliary drainage
|How to cite this article:|
Dar MA, Choh N, Rafiq S, Shaheen F, Ali S, Robbani I. Left versus right-sided percutaneous transhepatic biliary drainage in relief of malignant obstruction. Matrix Sci Med 2020;4:103-7
|How to cite this URL:|
Dar MA, Choh N, Rafiq S, Shaheen F, Ali S, Robbani I. Left versus right-sided percutaneous transhepatic biliary drainage in relief of malignant obstruction. Matrix Sci Med [serial online] 2020 [cited 2020 Oct 27];4:103-7. Available from: https://www.matrixscimed.org/text.asp?2020/4/4/103/297638
| Introduction|| |
The most common causes of malignant biliary obstruction (MBO) include pancreatic adenocarcinoma, hilar cholangiocarcinoma, ampullary/duodenal adenocarcinoma, gallbladder adenocarcinoma, lymphoma, and compressive metastatic proximal lymph nodes., The most common cause in our country is carcinoma of the gallbladder. Biliary tree obstruction and consequent jaundice occur in 70%–90% of these patients and have important consequences mainly for the patient's quality of life, morbidity, and overall mortality.,,,, Despite technological advances, only 20% of periampullary tumors are found to be resectable at the time of presentation due to their invasiveness, late symptom appearance, and onset in elderly people,,, and hence, effective palliation is the goal of the treatment.,
In recent years, endoscopic retrograde biliary drainage has overtaken percutaneous transhepatic biliary drainage (PTBD) as the initial procedure of choice in patients with distal bile duct obstruction., PTBD is a procedure to drain the bile ducts in the presence of a blockage or damage that prevents normal bile drainage. It has been shown that even if only 30% of the liver parenchyma is drained, it provides adequate palliation to relieve jaundice and associated pruritus.,
- Decompression of the dilated biliary tree due to malignant tumors, strictures,, primary sclerosing cholangitis, undergoing liver transplants
- Diversion of bile leak.,
- Transhepatic brachytherapy for cholangiocarcinoma
- Interventions in form of stent placement across a stricture, stone extraction, etc.
Right versus left percutaneous transhepatic biliary drainage,,
The appropriate puncture site is chosen based on the status of primary confluence, secondary confluence, and atrophy of liver parenchyma. For asymmetric liver function (atrophy, portal vein abnormalities), more benefit will be derived from drainage of the better functioning lobe.
Advantages of right-sided drainage
- Favorable anatomy for subsequent intervention
- Larger drainage catchment
- Less radiation exposure to operator during placement and subsequent PTBD changes.
Disadvantages of right-sided drainage
- More painful for patient
- More chances of accidental slippage due to constant motion of the drainage catheter in the intercostal space during respiration.
Advantages of left-sided drainage
- Less painful (avoids intercostal nerves)
- Less morbidity (avoids blood vessels)
- Preferred in ascites (due to relatively less pericatheter leak of ascites)
- More easily accessed and less likely for drain to fall out (better patient care).
Disadvantages of left-sided drainage
- Difficult or impossible in cases of atrophic or a high-riding left hepatic lobe
- More likely to access a central duct instead of a preferred peripheral approach
- More radiation exposure to performer's hand.
Complications are divided into minor and major
- Minor complications
- Pericatheter leak (bile leak along catheter) is a frequently observed complication
- Low-grade fever.
- Major complications
- Hemobilia and sepsis
- Hypovolemia: Electrolyte and fluid loss from the procedure can be substantial
- Bile leakage, catheter dislodgment and wound infection
- Pneumothorax and biliothorax
- Death (1.7%).
- Uncorrected coagulopathy
- Massive ascites.
- Multiple intrahepatic obstructions
- Multiple hepatic cysts.
Aims and objectives
To evaluate the usefulness of the left lobe versus right lobe PTBD in terms of:
- Relief of malignant obstruction and symptoms of same
- Changes in mean laboratory data.
| Materials and Methods|| |
- This study was a prospective, hospital-based study done in SKIMS, Soura from 2015 to 2017.
- PTBD was performed either through right (subcostal or intercostal) in 16 patients or left-ductal (sub-xiphoid) approach in 15 patients.
Planning of intervention
Prior to the initiation of procedure, three-dimensional cross-sectional imaging, i.e., (computed tomography or magnetic resonance imaging ± magnetic resonance cholangiopancreatography) of patients were reviewed to help identify dilated ducts and/or the level of obstruction for the consideration of a target.
Evaluation of the patient's coagulogram, liver, and kidney function was needed. Most patients need contrast administration for cholangiogram which can derange renal function.
- Patients with confirmed diagnosis of malignant obstructive jaundice who were surgically unresectable
- Unresectable malignant tumor, biliary stricture with failed ERCP.
- Patients with severe coagulopathy
- Patients with severe ascites
- Refusal to participate in the study.
The patients were asked to have nothing by mouth several hours before the procedure (≥4 h for conscious sedation) along with good intravenous access. Prophylactic antibiotics were started before the procedure along with conscious sedation with midazolam and fentanyl. Informed consent was taken from each patient. Monitoring of vital signs (blood pressure, pulse, and oxygenation status) was done during and after the procedure.
Technical success, clinical success (decrease in serum bilirubin level of more than 20% relative to baseline within 1 week after catheter insertion), change in other laboratory parameters (bilirubin, alanine transaminase [ALT], alkaline phosphatase [ALP], and albumin) before and after intervention (7th day), rate of internalization (catheter in the second part of the duodenum), and survival were compared in both groups.
Survival was calculated in days from the day of intervention until death or last follow-up was assessed.
The Chi-square test was used for the comparison of noncategorical variables which include sex, symptoms of the disease, and internalization. t-test was used for the comparison of pre- and post-intervention bilirubin levels, ALT, ALP, and albumin levels. The t-test for equality of means (Levene's test) was used to determine the age-distribution and to calculate mean survival rates in the two groups. The level of statistical significance was set at P ≤ 0.05.
| Results|| |
- The age of patients ranged from 48 to 76 years with maximum number of patients in the age group of 55–65 years
- There were about 53.3% males and 46.7% females in the left-sided approach. The corresponding figures in right-sided approach were 56.3% and 43.8%, respectively
- The principle causes of jaundice in maximum number of patients were malignant obstruction due to GB carcinoma (35.48%), followed by hilar cholangiocarcinoma (32.25), metastases (22.58%), and pancreatic/periampullary carcinoma (9.67%) [Figure 1]
- Rate of technological success (successful deployment of external/internal drainage) was 100%
- Clinical success was seen in 93.33% (14/15) cases in left and 93.75 (15/16) cases in right-sided group
- There was a significant reduction in bilirubin, ALT, and ALP levels after the procedure in both the approaches, but the decrease was more in the right-sided approach [Figure 2], [Figure 3], [Figure 4]. Only the decrease in bilirubin levels was statistically significant (P = 0.01)
- There was a decrease in serum albumin level as well which was attributed to the progression of the disease
- Internalization was done in 86.67% patients in the left-lobe approach [Figure 5], whereas in the right-lobe approach [Figure 6], it was done in 93.75% of patients
- The mean survival rate was almost similar in the right-lobe approach (139.5 days) than in the left-lobe approach (137.7 days) [Figure 7].
|Figure 1: Pie chart revealing the etiology of malignant obstructive jaundice|
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|Figure 2: Flouroscopic image revealing left-sided internal catheter. The distal end of the catheter is seen in the duodenum|
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|Figure 3: Fluoroscopic image revealed right-sided internal catheter within the duodenum|
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|Figure 4: Comparison between pre-and post-percutaneous transhepatic biliary drainage bilirubin levels|
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|Figure 5: Comparison between pre- and post-percutaneous transhepatic biliary drainage alanine transaminase levels|
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|Figure 6: Comparison between pre- and post-percutaneous transhepatic biliary drainage albumin levels|
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| Discussion|| |
Technical success in the left group was 100% (15/15), and in the right group, it was 100% (16/16). In the study reported by Saluja et al., the technical success achieved was 93% in the PTBD group. Better technical success in our study could be attributed to the advancement in micropuncture needles, guidewires, and catheters.
Percentage reduction change in bilirubin, ALT, ALP and albumin, pre-and-post PTBD was more in the right-sided approach as compared to the left-sided approach because 55%–60% of liver volume is drained by right hepatic duct while as only 35% of liver volume is drained by left hepatic duct. Reduction in bilirubin was attributed to the progression of underlying malignancy. Greater rate of internalization in right-sided approach is attributed to the fact right biliary duct is more in line with common hepatic duct and also because of the favorable angle between the two.
| Conclusion|| |
Our data support the fact that PTBD is an excellent procedure to drain the bile ducts in the presence of a blockage or damage that prevents normal bile drainage. Our results show that even though the survival of patients with MBO is dismal and most of the patients succumb to their illness, the survival of these patients can be enhanced significantly by subjecting them to biliary drainage, and the prognosis (survival) can be predicted in terms of their clinical and laboratory improvement. In our study, the reduction in bilirubin, ALT, and ALP was more in the right-lobe approach, but the decrease in albumin was more in the left-lobe approach. However, only reductions in bilirubin levels were found to be statistically significant. The decrease in albumin was attributed to the progression of malignant disease process. Our data also concludes that there is a significant decrease in symptoms after PTBD which is slightly more in the right-lobe approach than in the left-lobe approach.
PTBD causes a significant reduction in the bilirubin level, irrespective of the amount of liver drained or the type of drainage (external/internal). However, depending upon whether right or left-lobe approach is used, the outcome of the intervention in terms of clinical improvement, laboratory improvement, and complications varies.
The authors would like to thank the department of surgical and medical gastroenterology.
Financial support and sponsorship
SKIMS administration provided significant help in the form of free infrastructure.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Parasher G, Lee JG. The role of ERCP in pancreatobiliary malignancies. Advanced Digest Endoscopy 2006;6:120-41.
van Berkel M, Fockens P, Bruno MJ. Palliation of malignant pancreatobiliary obstruction. In: Clinical Gastrointestinal Endoscopy. Vol. 54. Philadelphia, Pa, USA: Saunders; 2005. p. 821-37.
Malkan G, Mohandas KM. Epidemiology of digestive cancers in India. I. General principles and esophageal cancer. Indian J Gastroenterol 1997;16:98-102.
Ballinger AB, McHugh M, Catnach SM, Alstead EM, Clark ML. Symptom relief and quality of life after stenting for malignant bile duct obstruction. Gut 1994;35:467-70.
Abraham NS, Barkun JS, Barkun AN. Palliation of malignant biliary obstruction: A prospective trial examining impact on quality of life. Gastrointest Endosc 2002;56:835-41.
Sauvanet A, Boher JM, Paye F, Bachellier P, Sa Cuhna A, Le Treut YP, et al
. Severe jaundice increases early severe morbidity and decreases long-term survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. J Am Coll Surg 2015;221:380-9.
Bonnel D, André T, Mader B, Lefebvre JF, Bensoussan E, Liguory C. Malignant biliary obstruction, general review and clinical practice. Bull Cancer 2013;100:443-52.
Deviere J, Baize M, Gelin M, Desmarez B, de Toeuf J, et al
. Treatment of cancer of the head of the pancreas. Surgery and/or endoscopic prostheses. Acta Gastro Enterologica Belgica 1987;50:137-46.
Ryan DP, Hong TS, Bardeesy N. Pancreatic adenocarcinoma. New England J Med 2014;371:1039-49.
Burke EC, Jarnagin WR, Hochwald SN, Pisters PW, Fong Y, Blumgart LH. Hilar cholangiocarcinoma: Patterns of spread, the importance of hepatic resection for curative operation, and a presurgical clinical staging system. Ann Surg 1998;228:385-94.
Albores-Saavedra J, Schwartz AM, Batich K, Henson DE. Cancers of the ampulla of Vater: Demographics, morphology, and survival based on 5,625 cases from the SEER program. J Surg Oncol 2009;100:598-605.
Kumaran V, Gulati S, Paul B, Pande K, Sahni P, Chattopadhyay K. The role of dualphase helical CT in assessing resectability of carcinoma of the gallbladder. EurRadiol 2002;12:19939.
Bismuth H, Castaing D, Traynor O. Resection or palliation: Priority of surgery in the treatment of hilar cancer. World J Surg 1988;12:3947.
Speer AG, Cotton PB, Russell RC, Mason RR, Hatfield AR, Leung JW, et al
. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987;2:57-62.
Van Leeuwen DJ, Huibregtse K, Tytgat GN. Carcinoma of the hepatic confluence 25 years after Klatskin's description: Diagnosis and endoscopic management. Semin Liver Dis 1990;10:102-13.
Polydorou AA, Cairns SR, Dowsett JF, Hatfield AR, Salmon PR, Cotton PB, et al
. Palliation of proximal malignant biliary obstruction by endoscopic endoprosthesis insertion. Gut 1991;32:685-9.
De Palma GD, Galloro G, Siciliano S, Iovino P, Catanzano C. Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: Results of a prospective, randomized, and controlled study. Gastrointest Endosc 2001;53:547-53.
Becker CD, Glättli A, Maibach R, Baer HU. Percutaneous palliation of malignant obstructive jaundice with the Walls stent endoprosthesis: Follow-up and reintervention in patients with hilar and non-hilar obstruction. J VascInter Radiol 1993;4:597-604.
Gamanagatti S, Singh T, Sharma R, Srivastava DN, Dash NR, Garg PK. Unilobar versus bilobar biliary drainage: Effect on quality of life and bilirubin level reduction. Indian J Palliat Care 2016;22:50-62.
] [Full text]
Navaneethan U, Jayanthi V. Endoscopic management of biliary leaks. The answer for the future. Minerva Gastroenterol Dietol 2008;54:141-50.
Yee AC, Ho CS. Complications of percutaneous biliary drainage: Benign vs malignant diseases. AJR Am J Roentgenol 1987;148:1207-9.
Link BC, Yekebas EF, Bogoevski D, Kutup A, Adam G, Izbicki JR, et al
. Percutaneous transhepatic cholangio drainage as rescue therapy for symptomatic biliary leakage without biliary tract dilation after major surgery. J Gastrointest Surg 2007;11:166-70.
Gossage MR, Short RF, Wael E. Percutaneous transhepatic biliary drainage. Saad 2012;110:501-8.
Chandrashekhara SH, Gamanagatti S, Singh A, Bhatnagar S. Current status of percutaneous transhepatic biliary drainage in palliation of malignant obstructive jaundice: A review. Indian J Palliat Care 2016;22:378-87.
] [Full text]
Harbin WP, Mueller PR, Ferrucci JT Jr. Transhepatic cholangiography: Complicatons and use patterns of the fine-needle technique: A multi-institutional survey. Radiology 1980;135:15-22.
Ring EJ, Kerlan RK Jr. Interventional biliary radiology. AJR Am J Roentgenol 1984;142:31-4.
Morgan RA, Adam A. Percutaneous management of biliary obstruction. In: Gazelle GS, Saini S, Mueller PR, editors. Hepatobiliary and Pancreatic Radiology Imaging and Intervention. New York: Thieme; 1998. p. 677-709.
Saluja SS, Gulati M, Garg PK, Pal H, Pal S, Sahni P, et al
. Endoscopic or percutaneous biliary drainage for gallbladder cancer: A randomized trial and quality of life assessment. Clin Gastroenterol Hepatol 2008;6:944-50000.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]