Hepatobiliary Surgery - part 3 docx

48 Hepatobiliary Surgery 4 Fig. 4.2B. Middle phase image at the same level looks similar. The three lesions are demonstrated. Fig. 4.2C. Late phase images. The three lesions are seen on these two images. The lesion in Segment VIII and the lesion in the lateral aspect of Segment II/III are very low attenuation and likely to represent cysts. The small mass medially in the left liver (arrows) is most likely a metastasis. 49 Interventional Radiology in Hepatobiliary Surgery 4 Fig. 4.2D. Early phase image at the level of the porta. There is an area of low attenuation anteriorly in Segment IV, abutting the umbilical fissure. Therapeutic and Palliative Procedures Percutaneous Cholecystostomy General Considerations Percutaneous cholecystostomy (PC) is generally performed in patients with acute cholecystitis who are too ill to undergo cholecystectomy. The procedure is most often performed in acute acalculous cholecystitis. Acalculous cholecystitis typically occurs in elderly and/or extremely ill patients, frequently in the intensive care unit. Definitive diagnosis may be difficult, but should be suspected in this patients in whom there is no other explanation for fever and leukocytosis, or when the gallbladder is distended and tender. PC may represent definitive treatment in these patients. Given the relative ease and safety, of performing PTC, most interventional radiologists have a low threshold for performing this procedure in the appropriate clinic situation. PC may also be performed in cases of calculous cholecystitis in patients consid- ered poor operative candidates. When gallstones are present, the ultimate treatment depends on the clinical situation. The procedure may be temporizing in patients whose condition improves enough to allow for definitive cholecystectomy. In pa- tients who remain poor surgical candidates, stones may be removed percutaneously from the gallbladder or common bile duct, and balloon sphincterotomy may be performed. Rarely, PC may be performed to provide biliary drainage in cases of distal obstruction. 50 Hepatobiliary Surgery 4 Fig. 4.2E. Late phase image at the same level. No mass is demonstrated. This is a characteristic location for a perfusion artifact, which is what this “lesion” represented. Fig. 4.2G. Early phase image in the lower liver demonstrating a metastasis in Segment VI. 51 Interventional Radiology in Hepatobiliary Surgery 4 Fig. 4.2H. Middle phase image in the lower liver demonstrating a metastasis in Segment VI. Fig. 4.2I. Late phase image in the lower liver demonstrating a metastasis in Segment VI. 52 Hepatobiliary Surgery 4 Technique PC may be performed under ultrasound or CT guidance or even at the bedside in patients too ill to be transported to the interventional suite. In most cases of acalculous cholecystitis, thick dark bile is aspirated at the time of drainage. As in- flammation subsides and cystic duct patency is restored, bile will begin to drain. Cystic duct patency can be confirmed with a contrast study and the tube can be capped until the tract has matured (we generally wait at least 3 weeks), at which point the tube can be removed. Percutaneous Biliary Drainage Indications Percutaneous biliary drainage is indicated in cases of obstructive jaundice caus- ing cholangitis or intractable pruritus, or where an elevated bilirubin precludes other treatment. This latter situation occurs most commonly in patients requiring chemo- therapy, but may also apply in patients being considered for hepatic embolization. Asymptomatic jaundice does not require treatment. In particular, intervention solely to reduce a high bile duct obstruction (at or above the confluence) may cause many more problems than it solves. We usually try to avoid treating patients when cross sectional imaging suggests subsegmental isolation, as the goals of drainage can rarely be accomplished. Preoperative biliary drainage remains controversial except for the treatment of biliary sepsis. The hepatobiliary disease management team should evaluate each patient to determine the need for drainage. Once the need for drainage is determined, con- sideration should be given as to whether an endoscopic or percutaneous drainage approach is more appropriate. In general, patients with low bile duct obstruction are managed endoscopically by the gastroenterologists. Percutaneous drainage is reserved for cases of high bile duct obstruction or for patients whose biliary tree cannot be accessed endoscopically (e.g., previous bypass procedure or gastric or duodenal tumors). Technique As with PTC, the optimal approach to the biliary tree is determined by many factors. Good quality diagnostic imaging is essential for proper planning of a percu- taneous biliary drainage. It is important to identify the level of obstruction, the status of the portal vein, the presence of hepatic atrophy or ascites, and the extent of parenchymal disease. Operator preference, while important, is secondary to the need to maximize the safety and efficacy of the procedure. Punctures are generally performed using 21 or 22 gauge needles. Right-sided drainage is performed from a lower intercostal or, when possible, subcostal approach. Left-sided drainage is generally performed from an epigastric approach (Figs. 4.3A-F). We use a 21-gauge diamond tipped, two-part needle for the initial punctures. After the needle is inserted into the liver, contrast is injected until the biliary tree is opaci- fied. Multiple passes may be necessary until a duct is visualized. If the initial duct punctured is not optimal for placement of a drainage catheter, a second needle is used to puncture a suitable duct once the ducts have been filled with contrast. The optimal duct for drainage should be peripheral so as to avoid large, central vessels, 53 Interventional Radiology in Hepatobiliary Surgery 4 and also to provide enough intraductal space above the level of obstruction for an adequate number of catheter side holes through which the bile will drain. Once a suitable duct is punctured, the needle is exchanged over a small (.018) guide wire for a three part system consisting of a thin metal stiffener, a thin inner introducer sheath, and a 7F outer introducer sheath. The inner two pieces are re- moved leaving the outer portion of the introducer, through which catheters and wires of appropriate size to perform the drainage can be placed. Generally, every attempt is made to cross through the obstruction in order to allow placement of an internal-external drainage catheter that has a loop in the duodenum and side holes above and below the level of obstruction. The interventionalist has a large armamentarium of catheters and guidewires to facilitate passage through various types of obstructions. At times, an obstruction cannot be negotiated nor is it preferable to minimize manipulation in the setting of sepsis; in these cases an external catheter is placed initially. Attempts are generally made at a later time to convert the initial catheter to an internal-external catheter. At the time of initial drainage, bile specimens are obtained for culture and, if necessary, cytology. Brush biopsy can also be performed, either initially or as a second procedure. Depending on the level of obstruction, the goals of drainage may not be accom- plished with one catheter. The higher the obstruction, the less likely it is that one drainage will suffice. It is unnecessary to drain every hepatic segment in order to normalize bilirubin and relieve pruritus. Unfortunately, the need to drain multiple segments seems more common in the setting of cholangitis, where isolated systems are contaminated and continue to cause symptoms in the absence of drainage. As mentioned previously, we ardently avoid treating patients where cross sectional im- aging suggests subsegmental isolation, but will at times place as many as three drain- age catheters (generally one left-sided catheter, one catheter in the right anterior sector and one in the right posterior sector). Whereas each catheter is difficult for the patient to tolerate, every effort is made to use as few catheters as possible. Complications With the advent of micropuncture technology, targeted punctures, and improved antibiotics, biliary drainage is much safer now than when first developed. Major complications include bleeding and sepsis. Coagulopathy must be addressed prior to drainage and all patients should receive prophylactic antibiotics. Complications such as pneumothorax and biliary-pleural fistula are very uncommon. Internal Stent Placement General Considerations Internal stents may provide drainage with improved quality of life compared to percutaneous drainage catheters. Most interventionalists place self-expanding, flexible metallic stents. Metal stents cannot be changed, and because of limited duration of patency (generally 5-7 months) they are rarely employed in benign disease (Figs. 4A-D). Plastic stents can be placed percutaneously and may be appropriate in certain situations. While most patients and referring physicians are anxious to have percutaneous drainage catheters converted to internal stents as quickly as possible, it is important 54 Hepatobiliary Surgery 4 to consider each case carefully to determine the appropriate timing for internaliza- tion. In general, when one is confident that no future drainage procedures will be necessary or possible, it is appropriate to place an internal stent. In cases of low bile duct obstruction, stent placement may be primarily performed. In cases where a stent would extend above the confluence, the stent may interfere with future inter- ventions and placement should be delayed until all necessary drainage procedures have been performed. Multiple stents may be placed at the same time. Nearly all metallic biliary stents are self expanding. Balloon dilatation is extremely painful, and is rarely, if ever, indicated. In general, if a stent is not fully expanded immedi- ately (as is often the case), a small angiographic catheter (usually 5F) may be left through or above the stent to maintain access to the biliary tree. The patient is brought back to the interventional suite the following day to assess stent expansion and function. If for any reason an additional stent is needed, it is placed at that time. The small “covering” catheter is removed only after stent adequacy is documented. Other Transhepatic Percutaneous Biliary Interventions Percutaneous, transhepatic biliary access may also be used to allow balloon dila- tion of strictures, removal of intrahepatic stones, and delivery of brachytherapy or other intraductal therapies. Figs. 4.3A-F. Percutaneous biliary drainage catheter placement and subsequent conversion to Wallstent® (Boston Scientific, Watertown, MA) in a patient with meta- static pancreatic carcinoma. The patient had undergone a gastrojejunostomy and could not be approached endoscopically. Fig. 4.3A. Contrast enhanced CT image showing hepatic metastases, more pronounced in the right hemiliver. Both the right and left portal veins are patent. 55 Interventional Radiology in Hepatobiliary Surgery 4 Most interventional radiologists and surgeons agree that the best long-term out- come for treatment of bile duct strictures can be expected from primary repair by an experienced hepatobiliary surgeon. Surgical success may be more limited in patients who are poor surgical candidates, have portal hypertension, or who have had previ- ous attempts at surgical repair. These patients may best be treated with percutane- ous drainage and balloon dilatation. The best results of percutaneous treatment can be expected in cases of short segment, late presentation, low bile duct strictures. Balloon dilatation is generally performed as a staged procedure after placement of a percutaneous drainage catheter. Strictures well below the confluence can gener- ally be treated with one balloon. Strictures at or near the hilus may require two or more catheters that permit sequential or simultaneous dilation (using “kissing bal- loons”) at more than one site. After initial dilatation, a 10-12 F drainage catheter is left across the treated stricture(s) for approximately 4 weeks, at which time the pa- tient returns for cholangiographic evaluation. If narrowing persists, repeat dilation may be performed with a larger balloon, followed by another 4-week period with the drainage catheter across the treated segment. Once the stricture is shown to be well treated, a catheter is left above rather than across the treated area. This catheter is then capped, allowing a physiologic trial of the adequacy of dilation to be per- formed. If this is well tolerated by the patient, the catheter can be removed. Patients who fail repeated dilation may require long-term catheter drainage or an attempt at surgical repair or bypass. As mentioned earlier, due to limited long-term patency, we are hesitant to place metallic stents to treat benign disease. Stents may be placed in patients with limited life expectancy due to comorbid conditions or in other rare cases. A proposed etiology for restenosis after metal stent placement is that the metal Fig. 4.3B. Image from a left sided percutaneous biliary drainage shows the 21 gauge puncture needle in a peripheral lateral segment duct. 56 Hepatobiliary Surgery 4 wire in biliary stents may cause chronic irritation and mucosal hypertrophy. For this reason, we prefer to use a stent with the least amount of metal in contact with the duct wall to treat benign disease. Brachytherapy involves the local delivery of radiation and may be used to treat intraductal tumor. The radiation source is generally delivered via catheters placed through recently inserted metal stents. In addition to providing local treatment of tumor, brachytherapy may prolong the patency of metallic stents by decreasing the rate of tumor ingrowth. Percutaneous Abscess Drainage Percutaneous drainage techniques may be useful in treating patients with abdomi- nal abscesses, including hepatic abscess. Percutaneous drainage may be necessary to Fig. 4.3C. The needle was successfully exchanged for an angiographic catheter, which was advanced over a steerable wire to the duodenum. This catheter assembly was then exchanged for the internal-external drainage catheter shown here. The catheter extends from the lateral segment duct across the common hepatic duct occlusion and terminates with the distal pigtail in the duodenum. The image nicely depicts the level of obstruction and shows that this catheter drains both the right and left hemi-livers. 57 Interventional Radiology in Hepatobiliary Surgery 4 treat postoperative abscesses or other collections of fluid such as bile or infected ascites. Abscess can be diagnosed based on clinical and radiographic findings. Drainage catheters can be placed under CT, ultrasound, or fluoroscopic guidance. Fig. 4.3D. Immediately after conversion of the drainage catheter to a Wallstent®. The catheter has been removed over a guidewire, which extends via the lateral segment to the distal duodenum. The stent has not yet been opened or shortened to its stated dimensions and is seen extending from the distal 3rd duodenum to the left hepatic duct. [...]... 1994 Emond et al, 1995 Belghiti et al, 1996 Melendez et al† Transfusions (units or cc)** Median HVI 35 35 – – 8.0 ± 8 .3 HVI 16 13 1866 ± 16 83 132 5 – HVI 15 15 – – 5.8 ± 4.7 HVI 56 33 1651 ± 1748 1200 930 ± 750 HVI 48 44 1255 ± 1291 – 1.9 ± 2.6 HVI 24 24 1195 ± 1105 – 2.5 ± 3. 4 496 35 7 849 ± 972 618 0.9 ± 1.8 *Major resections include all lobectomies and extended lobectomies **Value are reported in... mortality 5 76 Hepatobiliary Surgery Table 5.2 Comparison of operative parameters between hepatic vascular isolation (HVI) and LCVP-aided hepatectomy (LCVP) Author Technique Total Cases Major Resections* Blood loss (cc) Mean** 5 Delva et al, 1989† Emre et al, 19 93 Hannoun et al, 19 93 Habib et al, 1994 Emond et al, 1995 Belghiti et al, 1996 Melendez et al† Transfusions (units or cc)** Median HVI 35 35 – – 8.0... antibiotics Hepatobiliary Surgery, edited by Ronald S Chamberlain and Leslie H Blumgart ©20 03 Landes Bioscience 74 Hepatobiliary Surgery Table 5.1 Preoperative factors associated with postoperative life-threatening complications or fatal cardiac complications History: Physical Examination: Electrocardiogram: General Status: 5 Operation: Age > 70 yrs Myocardial infarction in previous 6 months S3 gallop... major intra-abdominal procedures are bleeding, intravascular volume, renal function, and oxygenation There are also some unique issues in patients undergoing hepatobiliary surgery Liver regeneration following partial hepatectomy involves rapid cell division (as early as 2 4-7 2 hours) and may be critically dependent on cellular ATP stores Supplementation of intravenous fluids with KPO4 (3 0-4 0 mmol/day)... agents Indications Embolization is performed in an attempt to prolong survival in patients with hepatocellular carcinoma and non-neuroendocrine, hypervascular liver metastases Interventional Radiology in Hepatobiliary Surgery 63 4 Fig 4.4D Completion fluoroscopy demonstrates two well-expanded metallic stents within the right and left ductal system who are not surgical candidates Since neuroendocrine tumors... embolization Interventional Radiology in Hepatobiliary Surgery 69 4 Fig 4.6B Contrast enhanced CT image demonstrating the mass in Segment III before embolization Fig 4.6C Percutaneous portal venogram prior to embolization The catheter has been placed via a right portal venous branch, and the tip of the catheter is within the main portal vein 70 Hepatobiliary Surgery 4 Fig 4.6D Percutaneous portal venogram... embolization of the right portal vein Note the enlargement of the lateral segment and the unopacified portal vein branches in the right hemi-liver 72 Hepatobiliary Surgery 4 Fig 4.6H CT portogram image at the same level as “G.” Note the perfusion defect in the right hemi-liver CHAPTER 5 Perioperative Care and Anesthesia Techniques Mary Fischer, Enrico Ferri, Jose A Melendez Introduction The evolution of... complications is significantly reduced by β-blocker therapy Table 5.1 shows other factors associated with increased cardiac morbidity A complete history and physical examination, followed by a 12-lead EKG, are the basic components of the preoperative evaluation Radio-nucleotide stress test and echocardiography are used to assess the extent of the ischemic disease In men between 30 and 55 years, with a history... be performed as a “stand-alone” procedure We have found that patients are more likely to tolerate Interventional Radiology in Hepatobiliary Surgery 65 injection of the entire “calculated” ethanol volume when PEIT is performed the day after embolization then when it is performed alone Radiofrequency Ablation (RFA) RFA involves inserting a probe with an insulated shaft and un-insulated tip into a tumor... Po2 < 60 or Pco2 > 50 mm Hg, K < 3. 0 or HCO3 < 20 meq/l BUN > 50 or creatinine > 3. 0 mg/dl Abnormal SGOT, Signs of chronic liver disease or patient bedridden Intraperitoneal, intrathoracic or aortic operation Emergency operation *(modified from Goldman (1977), with permission of Massachusetts Medical Society, Boston) Hepatic Evaluation The operative outcome after liver surgery strictly depends on the . needles. Right-sided drainage is performed from a lower intercostal or, when possible, subcostal approach. Left-sided drainage is generally performed from an epigastric approach (Figs. 4.3A-F). We. 4.3A-F). We use a 21-gauge diamond tipped, two -part needle for the initial punctures. After the needle is inserted into the liver, contrast is injected until the biliary tree is opaci- fied. Multiple. veins are patent. 55 Interventional Radiology in Hepatobiliary Surgery 4 Most interventional radiologists and surgeons agree that the best long-term out- come for treatment of bile duct strictures