Transhepatic Biliary Drainage
What is Transhepatic Biliary Drainage?
Bile is a liquid made by the liver, which travels through tubes (ducts) to the intestine for the purpose of aiding digestion and eliminating some chemical waste from the body.
When the bile ducts become blocked, certain chemicals, including bilirubin can accumulate in the bloodstream and cause jaundice, a yellow color of the skin and eyes, and pruritis, a severe widespread itching. Blocked bile can become infected, causing a very serious inflammation of the bile ducts and bloodstream infection.
There are three ways that bile ducts can be unblocked – bile duct surgery, ERCP (done by a gastroenterologist doctor using a large tube or endoscope placed in the throat), or a transhepatic (through the liver) bile drainage performed by an interventional radiology doctor. In general, a transhepatic biliary drainage is done when ERCP has been unsuccessful and surgery is not considered appropriate.
How should I prepare?
Before the procedure, you should have blood tested to determine how well your blood clotting is functioning. You should inform your doctor of all medications you are taking, including any herbal supplements. Inform us of any allergies, particularly to local or general anesthetic medications or to contrast materials (sometimes called X-ray dye) or to latex gloves. Always inform your doctor if you are or may be pregnant.
Transhepatic biliary drainage will be done with heavy sedation or under general anesthesia, and usually during a hospital admission. Eat a light meal the evening before. You will be instructed not to eat or drink after midnight before the procedure, and if you are diabetic you should receive instructions from your doctor about adjusting medications and insulin dose on the day of the procedure. You will likely be asked to remove your clothing and wear a gown during the procedure.
How is the procedure performed?
The patient will be positioned on a fluoroscopy table where real-time X-ray imaging can be done. After the skin is cleansed and local anesthetic given, ultrasound and fluoroscopy are used to place a very thin, long needle through the skin and into the liver. Once the tip of the needle is in a bile duct, the needle will be exchanged over a wire for a thin plastic catheter, which is then advanced along the ducts and through the blockage, and into the duodenum (the first part of the small intestine).
The goal is to place a long plastic catheter with side holes (a stent) above and below the blockage, so that the bile produced by the liver can travel through the tube and be eliminated by the intestines. Initially, the bile will also be drained outward via the catheter into a drainage bag. Uncommonly, the catheter cannot be advanced through the blocked part of the bile duct at the first try, and the catheter must be parked in the bile duct for drainage into a bag. In that case a second procedure is usually attempted in 24 to 48 hours to advance the catheter through the blockage into the duodenum.
Decisions about the next step of care will be made after the patient has recovered from the procedure and the anesthesia.
What will I experience during and after the procedure and how will I get the results?
The sedation will make you very drowsy and relaxed. The local anesthetic will sting at the skin entry. The placement of the catheter through the blockage into the intestine may produce nausea and moderate discomfort. If general anesthesia is used, you will be fully asleep and in the care of anesthesia doctors for the duration of the procedure and the initial recovery. You will be closely monitored for a few hours after.
The catheter placement occasionally comes very close to a rib and can result in a pain with movement, but this generally resolves in a few days. Pain medicine may be given.
Your doctors will inform you whether the procedure is technically successful when you are recovered from sedation or anesthesia. Your blood tests will be monitored over the next few days and decisions will be made with you, regarding the next steps in dealing with the cause of the bile blockage.
What are the benefits and risks?
The most important benefit of unblocking the bile duct is to decrease the risk of serious bile infection. However, the procedure may cause an immediate wave of bloodstream infection which will be known by shaking chills and fever, and uncommonly a life-threatening illness known as sepsis. To prevent or decrease the severity of this reaction, you will be given IV antibiotics before the start of the procedure, and you will be managed in an intensive care setting immediately after the procedure.
Over a few days after the procedure, the effects of jaundice and itching will decrease.
Placing a transhepatic stent catheter through the blockage and into the duodenum allows bile to flow into the intestine, as it should naturally. The presence of the catheter in the duodenum may make possible a successful ERCP, or endoscopic placement of a completely internal metal stent that could not be placed initially. Alternatively, the presence of a plastic catheter in the bile duct may make surgery easier, after the effects of jaundice and the threat of bile infection have been reduced.
The placement of a biliary drainage catheter is therefore a first step and usually will be followed by other procedures or surgery. Occasionally, the overall situation may be that the plastic biliary stent is left in place for a long time, and then would require specific techniques to manage the catheter.
Any procedure that requires puncturing the liver carries a roughly 1 percent risk of serious internal bleeding requiring transfusion. Rarely another procedure is required if such bleeding does not stop.
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