Biliary Drain and Stenting

Biliary Drain Placement

• Pre-scan and choose duct more peripheral to avoid major blood vessels yet not too peripheral to give a decent transhepatic tract

  • Area of obstruction often guides access. If right and left thought to be connected, studies suggest left is more comfortable than right.

  • For non dilated systems, right is often better. More ducts to hit.

• Access the biliary tree

  • Can use needle in access kit or separate 22G IN-RAD, other chiba, 21G thinwall, etc.

  • Can use ultrasound (left or right) or fluoroscopy (usually only right, high risk with left).

    • Ultrasound - target longitudinal axis of duct or branch point for greater purchase.

    • Fluoroscopy (right) - mid-axillary line aiming superiorly towards T12 and slightly anterior centrally and slowly pulling back. Fan inferiorly with each pass.

  • Challenging /refractory / nondilated tricks

    • Two stick technique - trying to stick the biliary system centrally under fluoroscopy to opacify the biliary tree and use separate needle to access the biliary tree in a more favorable location.

    • Aim for peripheral portal vein bifurcation and stick crotch. Pull back slowly as the bile ducts should run nearby.

• Contrast injection to confirm access. Only bile duct and lymphatics should flow toward the hilum. 

• Advance 018 wire, e.g., one in the access kit or Nitrex

• Advance access catheter, e.g, Greb set, MAK NV, or Nuff set

• Cholangiogram through access catheter (RAO helps lay out ducts) 

• Cross obstruction if present

  • If infected, maybe not worth it. If the duct is dissected or perforated trying to cross, time to stop.

  • Nitrix and curved access catheter from Greb set can be successful. Other can exchange for Kumpe and glidewire. Advancing a sheath can also help for additional support.

  • Refractory cases: can use TIPS, RF wire, or magnets placed endoscopically and percutaneously

• Establish stiff wire access (e.g. amplatz)

• Dilate subcutaneous tract

• Advance and form biliary catheter. Ideally to have marker not within the parenchyma or jailing off ducts. 

• Secure catheter in place and apply dressing.

Benign Strictures

• Protocols vary - two general approaches are early upsizing to a large drain with cholangioplasty only as needed for initial upsizing vs serial cholangioplasty. Data seems to favor the former, e.g., this RCT suggested repeat cholangioplasty is unnecessary if good result with initial plasty.

  • Not helpful if fresh anastomosis (<1 month) that may secondary to edema or kink. Better to leave internal-external drain for 2 weeks and then repeat the cholangiogram.

  • More likely to be successful with shorter, more focal stricture.

  • End point: resolution of ductal dilation, easy passage of contrast, <20-30% residual stenosis. Transition to capped external drain for 1-2 weeks and then removed if no issues.

  • Whitaker Test (biliary): External biliary drain is attached to a 3-way stopcock, which is attached to a water manometer and infusion pump to measure the pressure in the biliary tree with infusion.

• Example protocol 1:

  • Place 8.5 or 10.2 Fr internal-external biliary drain -> serial upsizing every 1-2 weeks to 18-20 Fr -> routine exchange every 3 months for 6 months

  • Primary and secondary patency 81% and 88%, respectively during 20 +/- 12 months of follow up

• Example protocol 2:

  • Place largest internal-external drain tolerated (often 12 or 14 Fr) -> upsize every 2 weeks to a 16-18 Fr silastic drain (Heyer-Schulte) with cholangioplasty only as needed for upsizing -> routine exchange every 3 months for 6-12 months -> 2 week capping trial

  • 1, 2, 5, and 10 year patency of 84, 78, 74, and 67%, respectively

  • If failed -> surgical revision, biliary stent, or chronic drainage

• Duel catheter (“double barrel”) technique:

  • Cut a 14 Fr internal-external biliary drain ~3-5 cm from the skin

  • Place 8.5 Fr drain through the 14 Fr drain and out a side hole proximal to the stenosis for effective diameter at stenosis of 22.5 Fr with only a 14 Fr percutaneous access. Has also been done with a balloon catheter through a 14 Fr biliary drain.

  • One study reported 99% clinical success at 24 months with 9% recurrence at 6-26 months for anastomotic strictures

Endobiliary Biopsy

• Brush biopsy not great, yield ~50%

• Bile cytology with curved catheter just proximal to malignant obstruction can be diagnostic in 40-60%

• Clam shell kits with better tissue, can do with cholangioscopy with yield apparently 95%

Stenting

• Plastic stents - generally placed endoscopically but can be placed percutaneously. Require routine exchanges.

• Metal stents - generally for malignant strictures with poor prognosis (<1 yr to live)

  • Issues with long dwell times include clogging and migration. These can be removed percutaneously if necessary.

  • Classic teaching was that covered stents (e.g. Viabil, Gore) > bare metal stent in terms of patency. However, more recent studies such as this RCT show no difference in patency with bare metal stents more vulnerable to ingrowth and covered stents more vulnerable to clogging from sludge. ~50% occlusion in 10 months.

  • Ideal to avoid covering the cystic duct or coursing through the sphincter of Oddi if possible.

• Potential longer patency and better survival with endobiliary RFA (e.g. Habib, Boston Scientific) or external beam radiation applied to obstructing lesion. See this RCT and meta-analysis.

  • Activated for 90 sec followed by resting/cooling for 60 sec. Post ablation balloon sweep with balloon, e.g., Fogarty to clear debris

• Options for central/hilar obstructions

  • Stent across right to left with uncovered stent and balloon out the side into the CBD with additional stent in a T-configuration

  • Kissing stents into the right and left into a CBD stent in a Y-configuration

  • Uncovered stent from the right or left into the CBD and then balloon out the side into the contralateral side with additional stent in a Y-configuration

Choledocholithiasis

• Ideal to sweep stones into duodenum rather than out percutaneous access with Fogarty to Python balloon catheter. However, stones >6 mm require pre-sweep plasty of the ampulla and stone >15 mm require lithotripsy.