Radiological Interventional and Imaging procedures in management of patient with malignant obstructive jaundice

 INTRODUCTION

The biliary system consists of organs and ducts (bile ducts, gallbladder, and associated structures) that are involved in the production and transportation of bile.¹

There are multiple causes of biliary obstruction as gall stones, malignant obstruction by hepatic, pancreatic or common bile duct tumors, also inflammation of bile ducts may cause biliary obstruction. ^{2, 3}

Diagnosis of obstruction is achieved by non-invasive and invasive procedures: Non-invasive procedures include ultrasonography and MRCP; the invasive procedures include ERCP and PTC which has diagnostic and therapeutic role. ⁴

Malignant biliary tract obstruction (MBTO) is a frequent cause of jaundice. Primary pancreatobiliary tract cancers and other local cancers that can cause compression of the biliary tract (e.g., liver, gallbladder) account for approximately 80,000 new cancer cases MBTO can also arise from gallbladder, duodenal, and ampullary cancers; metastatic cancers; or malignant lymphadenopathy. ⁵

PTC is predominantly now performed as a therapeutic technique. There are less invasive means of imaging the biliary tree including transabdominal ultrasound. ⁶

Additionally, self-expanding metal stents can be placed across malignant biliary strictures to allow palliative drainage. Percutaneous placement of metal stents can be utilized when therapeutic ERCP has been unsuccessful; two types of biliary stent are used as metal and plastic types. ^{7, 8}

The purpose of the study was to evaluate the efficacy of different modalities of interventional              radiological and imaging procedures as Percutenous Transhepatic cholangiography (PTC), Percutenous Transhepatic drainage (PTD) and biliary stenting in management of patients with malignant obstructive jaundice.

PATIENTS AND METHODS

This study included 30 patients already diagnosed with malignant obstructive jaundice attending to Tanta Cancer Center (TCC) from MARCH 2021 to SEPTMBER 2021.

They were 19 male and 11 females. Their ages ranged from 37 to 75 years.

Inclusion criteria: Failed ERCP, Inoperable patients as patients with irresectable tumor, patients with cardiac dysfunction or renal impairment, Pre-operative for patients with malignant obstructive jaundice fit for operation and post-operative for management of complications, Patients with malignant obstructive jaundice who refused surgical operation.

Exclusion criteria: Patients with bleeding disorders, pregnancy (as there is high risk of radiation exposure).

Patients were subjected to the following:

Clinical assessment: History taking including: Patient's age, patient's complaint such as; yellowish discoloration of the skin and sclera, dark urine, abdominal pain, abdominal swelling, fever, rigors … etc and history      of; operations, primary tumor, previous biliary interventions. General examination: Patients were examined searching for; fever, cachexia, anemia … etc. Abdominal examination: Local abdominal examination was performed searching for; hepatomegaly splenomegaly, ascites, abdominal masses, palpable gallbladder etc.

Laboratory assessment: All patients were assessed by laboratory investigations including; total and direct serum bilirubin, alkaline phosphatase, serum liver enzymes including serum glutamic pyruvic transaminase (SGPT) and serum glutamic oxaloacetic transaminase (SGOT),prothrombin time and concentration.

Radiological assessment: All the patients were subjected to: Recent abdominal ultrasound: to confirm the patient's status, Triphasic CT study in cases of hepatic tumors, MRCP for detection of degree and levels of biliary obstruction (not for all) and direct cholangiography just before drainage through percutaneous approach.

Preprocedures preparation: Coagulation profile was assessed especially prior to biliary drainage procedures, prothrombin time was ascertained to be within suitable limits (No more than 4 seconds greater than the control) and platelet count not less than 80.000/mm3, otherwise they were corrected by administration of vitamin K, platelets and fresh frozen plasma, patients were fasting for 6-8 hours, procedures were explained to the patient, informed consent was signed by the patient or his/her relatives. Pulse oxymeter was available for patient monitoring. Oxygen supply was available for use. Aseptic conditions were ascertained, intravenous cannula was inserted, in patients prepared for biliary drainage: Prophylactic broad spectrum antibiotics were given 1 hour before the procedure and intravenous fluid infusion started just before the procedure and continued during it.

Percutaneous Transhepatic Cholangiography (PTC): PTC was done for all patients to confirm the diagnosis and as a primary step before percutaneous interventional techniques.

Interventional Radiological Techniques: The following different interventional radiological   techniques were done to our patients guided by their diagnosis, clinical state and strategy of management: External biliary drainage, internal- external biliary drainage, biliary endoprothesis: Metallic stent and plastic stent and combined percutaneous and endoscopic technique.

Percutaneous External Biliary Drainage: was done to drain the obstructed biliary system. The used catheters were: Pigtail catheters 8-12 F. and Femoral catheter 6-8 F.

Fig. 1: Percutaneous External Drainage pigtail catheter

Percutaneous Internal- External Biliary Drainage: This method was used to internally drain patients in case of duodenal infiltration which was a contraindication for endoprosthesis and if dilatation of the liver track to large size to be fit for stent caliber carried a high risk of bleeding or intolerable by the patient. Pigtail catheters were used (of 10 and 12 F caliber).

Endoprosthesis: Metallic: When GW can bypass the obstruction in these patients, 5F catheter is used to traverse the stricture over it. A memotherm self-expandable stent was introduced along the strictured segment. Plastic: In these patients the tract was dilated by serial dilators to the diameter of the stent. Plastic stent was inserted over the GW and inner 7-8 F catheter of stiffener and pushed by pusher which is of the same caliber of the stent.

Fig. 2: Percutaneous plastic Carey Coons stent

IV: Combined Endoscopic & Percutaneous Drainage Technique (Randez-Vous)

It was done when cannulation with ERCP was dillicult and the GW passed through the obstructed segment Percutenously.

Post-drainage care

Bed rest for 24 hrs, antibiotics are continued for 2 days after the procedure, daily flushing of the catheter by sterile saline (in patients with external and internal- external drainage), cholangiography was done 3 days after the procedure, when the bile flow decreases visibly (in patients with external and internal- external drainage) and the following parameters were studied: Clinical response to drainage, laboratory response to drainage and frequency of complications.

Statistical Methodology: Analysis of the data was performed by: Statistical program of Social Science (SPSS) windows version (8) on IBM Computer, Description of quantitative variables in the form of mean and standard deviation (SD), Description of qualitative variables in the form of number and percentage. Comparison of quantitative variables was confirmed by using paired t test to compare data in the same group. One way ANOVA (Analysis of variants) test to compare more than two groups as regard quantitative variable.

RESULTS

Table 1: Causes of malignant obstructive jaundice among study groups:

Cancer head of pancreas was the commonest cause (40%) of malignant obstructive jaundice in our study.

Table 2: Frequency of interventional procedures for study groups:

Follow up of the patients after the procedure was done by laboratory investigation (total bilirubin level). We chose the 15 day total bilirubin level as an indicator of therapeutic success. Among different groups in our study the lowest mean total bilirubin level 15 days after drainage was achieved with metallic stenting (3.8 mg/ml), while the highest mean total bilirubin level 15 days after drainage was seen in percutaneous external drainage (10 mg/dl).

Table 3: Comparison of total bilirubin before and after procedure among different study groups

** +ve  complications

** - ve à No complications

Table 4: Frequency of complications among different procedures

The highest rate of complication was among the percutaneous drainage group and the commonest occurring complication in the study was hemobillia.

Case No. (1)

Male patient aged 64 years old diagnosed to have periampullary carcinoma. Total bilirubin level reached 19 mg/dl. Internal-External drainage was done.

Fig. 3: (A): Ultrasound showed dilated CBD caliber reaching 11mm (arrow) with no detectable masses or stones inside its lumen. (B): PTC showed dilated IHBR and CBD till a tight obstructing stricture is seen (arrow). (C): A guide wire succeeded to cross the stricture into the duodenum (arrow). (D): A catheter passed through the stricture over the guide wire (arrow). (E): Inserted internal –external pigtail catheter with free contrast flow into the duodenum (arrow).

Case No. (2): Male patient aged 73 years old diagnosed to have distal CBD cholangiocarcinoma. Total bilirubin level reaches 23 mg/dl. Percutaneous plastic stent was inserted through left duct approach.

Fig. 5: (A): Ultrasound showed intrahepatic biliary radicales dilatation (arrow) more evident at the left side. (B): PTC through left duct puncture revealed dilated IHBR and CBD till its distal part where tight stricture was seen (arrow) with no detected contrast in the duodenum. (C): A guide wire was succeded to cross the stricture into the duodenum (arrow). (D): A dilator introduced over the guide wire crossed the stricture to the duodenum (arrow). (E): A percutaneous plastic stent was inserted with free flow of contrast into the duodenum (arrow).