Biliary Procedures

Biliary Procedures are interventional radiology techniques used to visualize the liver, bile ducts, the gallbladder and the gallbladder ducts. Several biliary procedures are outlined below.

What is a Percutaneous Cholangiogram?

A percutaneous cholangiogram is a type of x-ray examination of the bile ducts inside and outside the liver, performed after a contrast dye is injected directly into a liver bile duct.
The test is performed in a radiology department by a radiologist. You will be asked to lie on your back on the x-ray table. The upper right side of the abdomen is cleansed and a local anesthetic is given. A long, thin, flexible needle is then inserted through the skin into the liver.

With guidance from the fluoroscope (an X-ray machine that projects images onto a TV screen), the bile duct is located and the contrast dye injected. The contrast dye then flows through the ducts and can be seen on the fluoroscopic monitor.

How will the test feel?

There will be a sting as the anesthetic is given and some discomfort as the needle is advanced into the liver. You may be given medication for sedation and/or pain control. Generally, an X-ray causes little or no discomfort.

Why is the test performed?

Bile is a by-product of protein metabolism which is created in the liver and excreted into the intestines via the bile ducts. If bile cannot be removed from the body, it collects in the blood and is seen as a yellow discoloration of the skin and eyes (jaundice).

As well, the pancreas creates digestive fluids, which drain via a common bile duct into the intestine, and thus obstruction can prevent the drainage of the fluids and may cause pancreatitis (inflammation of the pancreas).

A percutaneous cholangiogram may distinguish between obstructive and non-obstructive causes of jaundice and pancreatitis. If there is an obstruction, it can then be located and described.

What an abnormal result means?

The results may show ducts that are dilated which may indicate there is an obstruction. The obstruction may be caused by infection, scarring, stones, or cancer in the bile ducts, liver, pancreas, or region of the gallbladder.
Additional conditions under which the test may be performed include the following:

• Biliary obstruction
• Cholangitis

What are the risks?

There is a slight chance of an allergic reaction to the contrast medium (iodine). There is a slight chance of excessive blood loss, blood poisoning (sepsis), and inflammation of the bile ducts.

Biliary Drainage Catheter Placement

During Biliary Drainage Catheter Placement, a tube is placed directly into the bile ducts of the liver in order to drain bile directly from the liver. Sometimes, this tube drains bile from the liver directly outside of the body (external drainage). If that is the case, the bile will drain directly into the bag that is attached to the tube. If possible, the radiologist may be able to position the tube so that it extends internally from the liver to the intestines (internal drainage). If that is the case, the bile will drain normally into the intestines. You will know if your tube is draining internally because it will not be attached to a bag. Instead, an internally draining tube will be "capped." Your Emory physician or radiologist will provide you with instructions for care of the drainage tube and bandage.

Biliary Stone Removal

Biliary stone removal may be performed by the interventional radiologist via a T-tube (drainage tube) previously placed by a surgeon during removal of the gallbladder. In this circumstance, the patient retains surgically inaccessible stone(s) in the common bile duct. Biliary stone removal is commonly performed by an endoscopist, but might also be accomplished through an existing biliary drainage catheter or as a combined procedure.

Biliary stone removal is generally performed 5 to 6 weeks following surgical placement of a T-tube to allow for bile duct drainage and maturation of the drainage tract. Once the tract is matured, a guidewire is inserted into the bile duct and the T-tube is removed. A sheath is then passed over the guidewire and the guidewire is removed. A basket or snare device may be inserted through the sheath to retrieve the ductal stones. Depending on the size of the stone, other techniques for stone retrieval through a T-tube tract may be employed, to include passing the stone into the small intestine or fragmentation of the stone to enable basket retrieval.

Biliary Stent Placement

Biliary stents provide temporary relief from biliary obstruction. The length of the stent is determined by the length of the stricture, and by the stricture’s ability to be dilated as well as the size of the endoscope channel. Multiple stents are sometimes used simultaneously.
Stents must be replaced every three to four months or when relevant to the patient’s welfare.

Cholecystostomy tube placement

The preferred treatment for acute cholecystitis is laparoscopic cholecystectomy. Conversion to open surgery may be necessary in cases where the anatomy is unclear or complications are encountered. Laparoscopic tube cholecystostomy remains an alternative to open surgery in cases where the gallbladder is judged too inflamed to allow for laparoscopic removal and in cases where the patient is too sick to tolerate a more extensive procedure. It also provides access for diagnostic cholangiography.

Laparoscopic tube cholecystostomy is safe and remains a useful option in select patients with complicated acute cholecystitis.

Cholecystostomy tube placement is often performed in patients with limited life expectancy but can have a significant impact on quality of life.