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1 All authors: Department of Radiology, The University of Chicago Hospitals, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637.
Received June 27, 2000;
accepted after revision August 16, 2000.
Address correspondence to J. M. Lorenz.
Abstract
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MATERIALS AND METHODS. Between January 1, 1995 and July 1, 1999, 120 pediatric percutaneous transhepatic cholangiography procedures were performed in 76 patients (34 boys, 42 girls; age range, 5 months to 18 years; mean age, 5.3 years). Patients had received left lateral segment, whole-liver, or split-liver transplant grafts. Retrospective review of all pertinent radiology studies and electronic chart review were performed.
RESULTS. A diagnostic cholangiogram was obtained in 96% (115/120) of all procedures and drainage catheter placement was successful in 89% (88/99) of attempts. In patients with nondilated intrahepatic bile ducts, a diagnostic cholangiogram was obtained in 92% (46/50) of procedures, and drainage catheter placement was successful in 76% (19/25) of attempts. Minor complications occurred in 10.8% (13/120) of procedures and included transient hemobilia with mild drop in hematocrit level (n = 2), mild pancretitis (n = 1), fever with bacteremia (n = 5), and fever with negative blood cultures (n = 5). Major complications occurred in 1.7% (2/120) of procedures and included sepsis (n = 1) and hemoperitoneum requiring immediate surgery (n = 1).
CONCLUSION. Percutaneous transhepatic cholangiography and biliary drainage can be performed with high technical success and low complication rates in pediatric liver transplant patients, even in those with nondilated intrahepatic ducts.
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Left lateral segment, whole-liver, and split-liver left-lobe transplant grafts were included in the study. A summary of the number of patients and procedures for each type of liver transplant graft is provided in Table 1. In patients with left lateral segment grafts, drainage of the donor Couinaud segments II and III ducts occurs across a single Roux-en-Y cholangiojejunostomy. In patients with whole-liver transplant grafts, biliary drainage occurs across a choledochojejunostomy or a choledochocholedochostomy. In patients with split-liver left-lobe grafts, the entire left lobe of the donor graft is used and biliary drainage occurs across a Roux-en-Y cholangiojejunostomy. Two patients were included in both the left lateral segment and the whole-liver transplant groups as a result of retransplantation during the course of the study. Indications for PTC are summarized in Table 2.
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Procedure
Before all procedures, patients with a prothrombin time greater than 17 sec
or platelet count less than 50,000/mm3 received blood products to
correct deficiencies. All patients received broad-spectrum antibiotics before
the procedure. The procedures were all performed under general anesthesia, and
additional subcutaneous 1% lidocaine was administered as local anesthesia.
Punctures into the liver were made with a 21-guage needle (Accustick II
Introducer System, Boston Scientific, Natick, MA; or Micropuncture System,
Cook, Bloomington, IN). Lateral punctures into the right lobe of the liver
were performed preferentially in patients with whole-liver grafts. An oblique
subcostal or subxyphoid approach was preferentially used in patients with left
lateral segment grafts. In 46 procedures, sonographic guidance was used in
addition to fluoroscopic guidance to guide needle placement. Our technique for
sonographically guided PTC involved using a 7-MHz transducer to visualize and
access the duct along a longitudinal rather than a transverse plane. This
orientation allowed real-time visualization of the needle along its entire
course while maintaining longitudinal visualization of the bile duct. To
prevent infiltrated air from obscuring future attempts using sonography, test
contrast material was not injected unless dimpling or deflection of the target
duct was verified sonographically during needle advancement. Dilute contrast
material was gently infiltrated while retracting the needle until a peripheral
bile duct was opacified (Figs.
1A and
2A). If a more central duct was
entered, a second needle was used to puncture a more peripheral duct after
opacifying the intrahepatic bile ducts. If no ducts were opacified on the
initial puncture, the needle was withdrawn to a subcapsular position,
redirected, and advanced again. If no ducts were opacified after five passes,
the needle was completely removed, and a second puncture was made adjacent to
the first puncture site. Although the exact number of needle passes was not
recorded in each case, the procedure was usually terminated after
approximately 25 needle passes, or after reaching the patient's pediatric
contrast dose limit (4 mL/kg).
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If the biliary—enteric anastomosis was widely patent and no stictures were observed in the biliary tree, no biliary drain was placed. If a drainage catheter was required, an 0.018-inch guidewire with a hydrophilic tip (V18 Control Wire; Boston Scientific) was used for duct cannulation in all cases. A standard 0.035-inch guidewire was then advanced through the Accustick or Micropuncture coaxial dilator into the small bowel. If necessary, an end-hole catheter was used to direct the guidewire through bile duct stenoses into the small bowel. The 0.035-inch wire was exchanged for a stiff 0.035-inch guidewire through a 5-French endhole catheter. The tract was dilated to accept a biliary drainage catheter (Ultrathane Biliary Drainage Catheter; Cook) ranging in size from 6-to 10-French, which was left to external gravity drainage (Figs. 1B and 2B). Most patients were inpatients; however, all outpatients were admitted overnight for observation after the procedure. The Society of Cardiovascular and Interventional Radiology guidelines regarding major and minor complications were used [3].
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Biliary Drainage
In 21 of the 115 procedures in which diagnostic cholangiograms were
obtained, drainage catheter placement was not indicated on the basis of the
findings of the cholangiogram. Drainage catheter placement was successful in
94% (88/94) of the remaining procedures. In the six procedures resulting in
failed duct cannulation, three procedures were performed in patients with left
lateral segment transplant grafts, and three procedures were performed in
patients with whole-liver transplant grafts. On an intent-to-treat basis,
there were 11 failed attempts at drainage catheter placement in 99 procedures,
resulting in a technical success rate of 89% (88/99). The 11 failed attempts
at drainage catheter placement include the five failed attempts at duct
opacification described previously for PTC and the six failed attempts at duct
cannulation. Eleven patients required two catheters because of multiple
strictures. Figure 3 shows
attempts, successes, and failures of biliary drainage.
Nondilated Ducts
In patients with nondilated intrahepatic bile ducts, diagnostic
cholangiograms were obtained in 92% (46/50) of procedures. In four procedures,
we were unable to opacify the biliary ducts because of technical difficulties,
and no further procedures were attempted. In 50% (25/50) of procedures,
drainage catheter placement was not attempted on the basis of the appearance
of the cholangiogram and the clinical information. Drainage catheter placement
was successful in 76% (19/25) of the remaining procedures. In the six failed
attempts, duct opacification was unsuccessful in four procedures, and duct
cannulation (after successful duct opacification) was unsuccessful in two
procedures. In the two latter cases of failed duct cannulation, a second
procedure was successful. Table
3 shows technical success rates for PTC and biliary drainage in
procedures involving nondilated versus dilated ducts.
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Complications
Complications occurred in 12.5% (15/120) of procedures. Complications
occurred in 8% (2/25) of the PTC procedures that did not progress to biliary
drainage and 14% (13/95) of the procedures that progressed to biliary
drainage. Table 3 shows
complication rates for PTC and biliary drainage in procedures involving
nondilated versus dilated ducts.
Minor complications occurred in 10.8% (13/120) of procedures and included transient hemobilia with mild drop in hematocrit level (n = 2), mild pancreatitis (n = 1), fever with bacteremia (n = 5), and fever with negative blood cultures (n = 5). Major complications occurred in 1.7% (2/120) of procedures and included sepsis (n = 1) and hemoperitoneum requiring immediate surgery (n = 1). The two major complications occurred during procedures requiring biliary drainage. The single major bleeding complication occurred in a 2-year-old girl with a left lateral segment transplant graft 2 days after liver transplantation. After eight punctures, the patient experienced an acute drop in blood pressure, and abdominal distention was observed. Active bleeding from the cut edge of the liver was noted at the time of emergent exploratory laparotomy. In the six patients with sepsis (n = 1) and transient bacteremia (n = 5), blood cultures grew Xanthomonas maltophilia, Pseudomonas aeruginosa, Corynebacterium species, Escherichia coli, vancomycin-resistant Enterococcus organisms, and coagulase-negative Staphylococcus organisms. All patients were treated with antibiotics and had uneventful recoveries. In the single case of mild pancreatitis, a 17-year-old boy with a whole-liver graft complained of abdominal tenderness after the procedure, and mild elevations of amylase and lipase levels were observed. The patient had an uneventful recovery in 1 week, after a course of medical therapy.
The 30-day mortality rate was 2.5% (3/120). All three patients who died were liver transplant recipients who had had severe underlying problems before PTC, including sepsis, renal failure, severe acute rejection, and graft-versus-host disease. None of the deaths were directly attributable to PTC.
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The most common biliary complications of pediatric liver transplantation are strictures and bile leaks, and placement of a biliary drainage catheter is usually the initial treatment. Biliary strictures may occur at the surgical anastomosis (Fig. 1A) or elsewhere in the biliary tree due to infectious, immunologic, or ischemic causes. Bile leaks usually occur in the first few weeks after transplantation, either at the surgical anastomosis, the roux limb, or the cut edge of a reduced-size graft [7]. In published adult series, percutaneous treatment of strictures and bile leaks often produces lasting results [9], but in pediatric series, eventual operative repair is required in most cases [5, 10]. Other biliary complications include intraparechymal biloma, choledocholithiasis, and cholangitis.
Our experience indicates that technical success rates of PTC and biliary drainage in children are similar to those in adults. In children with dilated ducts, our success rates for diagnostic cholangiography and drain placement were 100% and 93%, respectively, as compared with 97-100% in published adult series [11, 12]. In children with nondilated ducts, our success rates for diagnostic cholangiography and drain placement were 92% and 76%, respectively, as compared with 90% and 86% in a recent published adult series [4]. Our results for pediatric patients are well within Society of Cardiovascular and Interventional Radiology guidelines [3] for thresholds of technical success in adult patients with nondilated ducts (65% and 46% for diagnostic cholangiography and drain placement, respectively). We attribute our high technical success rates in part to our frequent use of direct sonographically guided needle puncture in pediatric patients. We have found that direct sonographic guidance of pediatric PTC markedly reduces the number of needle passes and contrast media dose required, and results in a high technical success rate. Using fluoroscopy alone without direct sonographic guidance, technical success rates are proportional to the number of needle passes [13], and multiple passes are often required in children. Limits of contrast media dose may be reached rapidly in small infants using this fluoroscopic approach. Ischemic or immunologic injury to the bile ducts can result in smaller ducts, which are reduced in number [14], further increasing the number of needle passes required for PTC. Our high technical success rate in duct cannulation is largely attributable to the use of a 0.018-inch wire with a stiff shaft and a hydrophilic tip. We find that the tip of this wire can be shaped easily with a short 90° angulation, which facilitates duct cannulation, even in cases involving nondilated bile ducts. The stiff shaft of this wire allows easy advancement of the Accustick or Micropuncture coaxial dilator through dense, fibrotic liver tissue.
Although, to our knowledge, no pediatric guidelines for complication rates of PTC and biliary drainage have been published, our results are within the major complication threshold of 10% recommended by the Society of Cardiovascular and Interventional Radiology [3] for adult procedures. The types of complications in our series are similar to most published adult series [15, 16] and include peritoneal bleeding, sepsis, hemobilia, fever, and pancreatitis. Some patients who have undergone liver transplantation may be more susceptible to bleeding complications of PTC. The major bleeding complication in our series occurred in a patient who had recently received a liver transplant. The risk of peritoneal hemorrhage in patients shortly after transplant may be increased due to the absence of a protective fibrous capsule around the transplantation graft. Color Doppler sonography may allow the operator to avoid puncturing major vascular structures while accessing a bile duct, which may result in fewer complications [17, 18]. Hemobilia, sepsis, and transient bacteremia may occur after traversal of vascular structures as a result of biliary—venous communication. The biliary catheter can serve as a biliary—vascular fistula if side holes are present in both the portal vein and biliary tree. The cases of a mild drop in hematocrit level with hemobilia in our series resolved after repositioning the catheter with all side holes advanced into the biliary tree. Bacteremia can result from a malpositioned drainage catheter causing fitula or obstruction, or from overdistention of an obstructed biliary tree during the cholangiogram causing reflux of bacteria-laden bile into the bloodstream. Despite the use of preprocedural broad-spectrum antibiotics, cases of procedure-related fever, bacteremia, and sepsis occurred; however, all patients responded to treatment with antibiotics.
Pancreatitis, which is a known complication of PTC, occurred in one patient in our series. Pancreatitis can result from either direct puncture and overdistention of the pancreatic duct or obstruction of the pancreatic duct by the biliary drainage catheter.
In conclusion, we found that PTC and biliary drainage can be performed with high technical success and low complication rates in pediatric patients who have undergone liver transplantation. Although a relatively large number of passes may be required to opacify a bile duct suitable for catheter placement when duct dilatation is absent, we achieved high technical success rates in patients with nondilated ducts. The types and incidences of complications in our series were similar to those seen in published adult series.
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