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Beth Israel Deaconess Medical Center Boston, MA 02215
I read with interest the article by Funaki et al. [1] describing their experience with percutaneous transhepatic cholangiography and drainage in patients with nondilated bile ducts. Because they apparently serve a busy hepatobiliary and transplantation practice, the authors should be interested in biliary access via the transjejunal route, which we wrote about in 1995 [2]. In patients who have had a surgically created bilioenteric anastomosis with an antecolic roux loop, the jejunum below the ducts can be percutaneously accessed, allowing access to the entire biliary tree, even when more than one anastomosis is present (i.e., left and right hepaticojejunostomies) and when the ducts are tiny. We perform this procedure in conventionally created roux loops, which become somewhat scarred against the anterior abdominal wall, allowing more stable access than might otherwise be anticipated through the bowel. The transjejunal procedure is often specifically requested by our hepatobiliary surgeons because it completely avoids liver trauma. In fact, at the time of operation, the surgeons now often place a radiodense marker (coronary ring marker) on the loop to facilitate later percutaneous entry. Without the radiodense rings, landmarks for puncture may include surgical clips, reference to previous intraoperative or postoperative cholangiograms, or localization of the loop on recent CT scans. As with the conventional transhepatic route, any additional interventions, such as balloon dilatation, stent placement, stone removal, and duct biopsy, can be performed via the jejunal access. This route is not used if the roux loop of the jejunum is retrocolic.
In our experience, we have found this transjejunal technique to be especially useful in patients with thin or "pruned" peripheral ducts, (i.e., transplant recipients), in those with irregularly strictured ducts (i.e., sclerosing cholangitis), in patients with more than one bilioenteric anastomosis, or in situations in which repeated percutaneous entry is anticipated (i.e., benign strictures, stones).
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University of Chicago Hospitals Chicago, IL 60615
We are aware of the transjejunal technique described by Dr. Perry and colleagues [1]. Unfortunately, most of our patients are not candidates for this type of intervention. In our hospital, the majority of patients with nondilated intrahepatic bile ducts requiring percutaneous biliary drainage have either sustained iatrogenic bile duct injuries or have undergone liver transplantation [2]. For obvious reasons, patients with iatrogenic bile duct injuries are not suited for transjejunal drainage. Furthermore, most liver transplants in our hospital are currently performed using a choledochostomy, which obviates the need for a roux loop. Even when a roux loop is used (e.g., in patients with primary sclerosing cholangitis), our transplant surgeons fashion a retrocolic roux loop because they feel it provides more favorable drainage compared with an antecolic loop (antecolic roux loops are more commonly performed in patients with malignancy). Thus, we see few patients with antecolic roux loops. Nevertheless, we agree that the transjejunal technique is valuable when applicable, especially in patients with severely diseased peripheral bile ducts. Other advantages of this approach include improved patient comfort, decreased incidence of hemobilia, and simplified access in patients who have more than one bilioenteric anastomosis. One drawback of this technique is that catheter position tends to be less stable than conventional transhepatic placement. We thank Dr. Perry for her interest in our paper and concur that the transjejunal technique merits consideration.
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