Percutaneous transhepatic cholangiography
Percutaneous transhepatic cholangiography ( PTC) is an interventional procedure is introduced in which, with the help of a thin hollow needle under fluoroscopic control percutaneously ( through the skin) by puncture of the liver X-ray contrast medium in the biliary tree.
In addition, it is possible using this access a derivative of bile to the outside to make a drainage (percutaneous transhepatic biliary drainage, or percutaneous transhepatic drainage PTCD, PTD) to eliminate a backlog in the bile ducts.
Introduction
In various benign or malignant diseases of the biliary tract or the liver may lead to an impoundment of bile ( cholestasis ) with the clinical picture of jaundice (icterus). Although today can often (eg by MRI including MRCP ) the underlying disease (eg, a calculus in the common bile duct efferent ) are detected. However, the treatment of a bile drainage problem is by means of a sectional imaging is not possible, just as a biopsy collection for histological ( histological ) examination. In addition, an MRI can not be performed in all patients (due to the magnetic effect). Therefore takes place, if appropriate, must be treated or biopsied, usually endoscopic biliary display with contrast agent injection ( ERCP) and intervention. Since the endoscopic access to the biliary tract from the duodenum is not always possible, such as tumor-induced constrictions or after gastric surgery, the PTC is used as a reserve method.
The PTC is a direct cholangiography in which a representation of the bile ducts inside and outside the liver is possible. Important to know is that the two join ( the larger right and smaller left ) lobe of the liver bile ducts draining into the so-called Hepatikusgabelung and derive the bile from the liver via the common bile duct ( the common bile duct ) into the duodenum. The presentation of the bile ducts in the PTC and ERCP is compared to MRI / MRCP and CT still represents the gold standard
Usually a PTC / PTCD is applied to two different groups of symptoms:
- Cholestasis ( damming of the biliary system by eg concretions in the bile duct system or inflammatory or tumorous changes of the bile duct system ) that are not accessible to the ERCP.
- Leakage in the bile duct system
Indications
1 Benign causes of Galleaufstau:
- Gallstones ( stone formation ), possibly with secondary (ie, formed therefrom ) cholangitis
- Primary sclerosing cholangitis
- Autoimmuncholangitis / autoimmune pancreatitis
- Ischemic bile duct changes after liver transplantation
2 Malignant causes of Galleaufstau:
- Cholangiocellular carcinoma (CCC)
- Hepatocellular carcinoma (HCC)
- Liver metastases
- Other space-occupying tumors that compress the common bile duct (eg enlarged lymph nodes or pancreatic cancer)
3 causes of leaks in the biliary system:
- Leaks after Whipple'schen operation due to a pancreatic head carcinoma
- Leaks after major liver surgery ( emergence of a so-called Gallefistel )
- Leaks after liver transplantation
Treatment of bile duct strictures with stents
Closure of the biliary system by cholangiocellular tumors, pancreas and gall bladder carcinomas or in the hilum of the liver metastases localized a cure can be tried only in 10-20% of patients surgically. A derivation of bile leads to regression of jaundice and thus to an improvement of the associated pruritus and inflammatory changes. The first use of Metallendoprothesen (stents ) in humans was carried out in the late eighties, by Palmaz first in vessels, soon after, but also in the bile duct system, including by Lammer and Gillams 1990. A number of randomized trials could now prove that biliary stents in the treatment of malignant obstructive jaundice can contribute to improving the quality of life.
The open attitude of the two Hepaticusäste and the DHC can be achieved both by means of plastic prostheses, and by means of metallic endoprostheses (stents ). The patency of metallic stents is superior to plastic prostheses ( meaning that they stay open longer and require fewer re- interventions ). Gecoverte ( with a plastic membrane covered ) metal stents in turn are superior to bare metal stents with respect to the patency rate. In addition to technical problems (higher risk of perforation of selbstexplantierenden stents, high Dislokationsrate of gecoverten stent grafts from the DHC in the intestine, more difficult intervention for closure of a metal stent, higher risk in subsequent operations should be carried out when electrically hemostasis ) and cost issues.
If only the efferent bile duct ( DHC ) must be stenosed and supplies, it can be permanently supplied on the access of the PTC / PTCD means of a self-expandable stent. If, however, a ( by tumor -related ) closure not only of the DHC, but also the two Hepaticusäste before (and thus a problem of bile flow from both lobes of the liver ) should be a bilateral PTC / PTCD. Then you should ( on both bile ducts into the DHC outworked parallel) stents a " reconstruction" of the hepatic and splinting of the joint DHC be tried by two. A sole stenting of only one Hepaticusastes (mostly from the right, because the right hepatic lobe is larger than the left ) may be chosen only if the expected survival of the patient is very short and the left liver is very small. From both sides introduced stents improve survival compared with only a one-sided stent.
Percutaneous transhepatic biliary drainage ( PTCD )
In the case of a stenosis or complete closure of the bile duct, it is possible to produce a derivative of the bile to the outside through the skin via a drainage ( plastic tube with a plurality of lateral holes ) on this puncturing ( percutaneous transhepatic cholangiography and drainage PTCD ). The bile then collects in a small plastic bag. This can drain the bile and the damming of the biliary tract is reduced. Such an external drainage impaired quality of life ( drainage needs to be changed every 4-6 weeks, showering or swimming with the derived outward drainage difficult possible). Therefore we try, if possible, the deposit of a metallic biliary prosthesis (stent ). The stent may also without an outer derivation allow the internal biliary drainage, depending on the underlying primary disease for many months.
Complications
Typical complication of PTC / PTCD is bleeding into the biliary tree (particularly for a malignant biliary tract disease ), both during the advance of the bile duct drainage as well as the access Nachdilatation before insertion of a stent. Such bleeding usually arise from a venous or portal venous vessel and can be treated was insufficiently activated by the deposit and leaving a large volume drainage. A further complication is Fistelverbindungen between the bile ducts and liver vessels. Fistulas to the hepatic veins and portal vein can be treated by rinsing. Arteriobiliäre fistulas (ie a puncture caused by connection of the biliary system with the liver artery), however, are potentially life threatening and must be treated quickly by an interventional embolization. Abscesses and super infected hematoma ( through puncture ) represent also although rare but dangerous complications
Alternatives
Endoscopic retrograde cholangiopancreatography ( ERCP)
The percutaneous PTC / PTCD provides access opposite the ERCP especially appropriate when tumor or inflammation caused a high degree of bile duct has occurred that has become impassable for ERCP probe. Access to the biliary tract via the mouth into the duodenum using an endoscope has (eg bile duct stones or bile drainage disorders in benign and malignant areas of narrowing ) revolutionized the treatment of biliary suffering about 30 years ago. With the help of the endoscope and thin catheter contrast medium is injected here under radiographic control to display and then be with different instruments, minimally invasive treatments (such as cleanings, deposit of bile drainage drainage ) made. This procedure is called endoscopic retrograde cholangiopancreatography ( ERCP). Modern metal mesh prostheses can be advanced and placed Papillotomy via the endoscope up high in the hilum. Only limited or not possible Endoscopic transition derivatives with respect to previous surgery ( n Z. Whipplescher operation, B - II gastric resection or after conditioning of a biliodigestive anastomosis ) or hilar obstruction and Hepatikusgabeltumoren.
MRI
A disadvantage of the PTC or PTCD is the high radiation exposure with fluoroscopy control. In contrast, in the open MRI provides the opportunity X-ray- free percutaneous biliary represent and dot means of a catheter. This method, however, is still limited and only very limited availability. Furthermore, not all PTC / PTCD materials, as well as the metal stent MRI -compatible, as they are attracted by the strong magnetic field.