Imaging Percutaneous Transhepatic Biliary drainage

Percutaneous Transhepatic Biliary Drainage

Objective

•   Drainage of obstructed biliary systems in cases of surgical obstructive jaundice

•   To treat cholangitis

•   Gain access to biliary tract for stone removal, stricture dilatation, stent placement.

Patient Preprocedure Preparation

•   Blood prothrombin time

•   Antibiotic cover 24 hours prior to procedure

•   Fasting for 6 hours

•   IV fluids and serum electrolytes baseline values

•   Surgical cleaning and draping of abdomen and right flank.

Position

Supine.

Anesthesia

•   IV sedation with diazepam

•   Local infiltration analgesia with 10 ml of 1% xylocaine

•   General anesthesia may be required in uncooperative patients.

Instruments

•   22 G, 20 cm long Chiba needle with stilet.

•   18 G, 20 cm long PVC sheathed needle with stilet.

•   0.035" or 0.038" diameter, 100 cm long J-shaped guidewire.

•   0.038" heavy duty straight guidewire.

•   Sterile surgical blades.

•   Graded teflon dilators 7F-10F.

•   Ring biliary drainage catheter 10F pigtail with multiple side holes extending about 10 cm above the pigtail.

•   Suture and needle for fixation of catheter.

•   Adhesive tape.

•   Connector.

•   3-way stopcock.

•   Collection bag.

•   Water soluble iodinated contrast 50-100 ml.

•   Syringes 20 ml, 10 ml.

•   Normal saline.

Procedure

   1.  Fluoroscopic guidance.

   2.  Patient positioned supine, right side toward operator.

   3.  Puncture site is in midaxillary line, choose intercostal space below maximum excursion of diaphragm.

   4.  Local analgesia infiltration.

   5.  Puncture intercostal space with 22 G neelde under fluoro­scopic guidance; direct needle toward Xiphisternum till the midline; remove stilet.

   6.  Perform cholangiography by injecting diluted (1:1) contrast while continuously withdrawing the needle.

   7.  As soon as bile ducts are opacified; stop withdrawing needle and inject more contrast till the entire biliary tree is opacified.

   8.  If no bileduct is opacified in the first attempt, repeat the procedure as above.

   9.  Once the biliary tract is opacified, under continuous fluoroscopic monitoring insert the 18 G sheathed needle through the same intercostal space to puncture a peripheral right lobe bile duct preferably a posterior branch.

10.  Withdraw stilette of needle-sheath assembly.

11.  Position of needle tip within a duct is confirmed by injecting few ml of contrast.

12.  Make a stab incision along needle.

13.  Remove cannula leaving the sheath in place.

14.  Insert guidewire through sheath into the biliary tract.

15.  Manipulate the guidewire into desired position if possible.

16.  Dilate tract over guidewire to 10F size.

17.  Insert biliary drainage catheter.

18.  Position catheter so that all sideholes are within the biliary tract/hepatic parenchyma.

19.  Remove guidewire.

20.  Connect catheter to collection bag.

21.  Suture catheter and skin wound.

22.  Secure catheter to skin wound.

23.  Secure catheter to skin with adhesive tape.

Complications

•   Bleeding

•   Biliary peritonitis

•   Cholangitis and septicemia

•   Electrolyte imbalance

•   Pneumothorax.

            *Alternatively, sonographic guidance can be used for perform­ing PTBD. This is specially indicated if the left sided ducts need to be drained. Puncture is made directly with the 18 G sheathed needle through the epigastrium. The remaining steps (10-22) are same as in the fluoroscopic guided technique.

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Imaging percutaneous nephrostomy

Percutaneous Nephrostomy (PCN)

Objectives

In cases of upper urinary tract obstruction:

•   Drainage of supravesical upper urinary tract

•   Pyonephrosis drainage and assessment of recoverable function

•   Access to upper urinary tract for stone removal, stricture dilatation, stent placement.

Patient Preparation

• Blood prothrombin time

•   Antibiotic cover if required

•   Fasting for 6 hours

•   Children to be well hydrated

•   Surgical cleaning and draping of the back.

Position

Prone with sandbang under abdomen.

Anesthesia

•   IV sedation with diazepam

•   Local infiltration analgesia with 1% xylocaine, 10 ml

•   General anesthesia may be required for infants and uncooperative children.

Instruments

•   18 G, 20 cm long needle with stilet

•   0.035" or 0.038" diameter, 100 cm long J-shaped guidewire

•   Sterile surgical blades

•   Graded teflon dilators 7F-10F

•   Drainage catheter 8F-10F, pigtail with multiple holes/Malecot catheter

•   Suture and needle for fixation of catheter

•   Adhesive tape

•   Connector

•   3-way stopcock

•   Urine collection bag.

Procedure

   1.  Sonographic or fluoroscopic guidance depending on operators’ convenience and choice.

   2.  Calyx to be punctured, chosen depending on indication for PCN.

   3.  Puncture as laterally as possible, through renal paren­chyma.

   4.  Puncture chosen calyx under guidance with 18 G needle.

   5.  Remove stilette of needle; pass guidewire. Check position of guidewire within pelvicaliceal system.

   6.  Stab incision along needle tract.

   7.  Dilate tract to one size above catheter size.

   8.  Place catheter in pelvicaliceal system over guidewire.

   9.  Remove guidewire.

10.  Connect catheter to urine collection bag.

11.  Suture catheter and skin wound.

12.  Secure catheter to skin with adhesive tape.

Complications

•   Perinephric hematoma

•   Hematuria.

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Imageing Antegrade Pylogra

Antegrade Pyelogram

Objectives

In cases of:

•   Poor or nonvisualised of urinary system on excretory urography.

•   Opacification of upper urinary tract for evaluating site and nature of obstruction.

•   To obtain urine specimen for cytology or culture.

Patient Preparation

•   Blood prothrombin time

•   Antibiotic cover if required

•   Fasting for 6 hours

•   Surgical cleaning and draping of the site of drainage.

Position

Prone with sandbag under abdomen.

Anesthesia

•   IV sedation with diazepam

•   Local infiltration analgesia with 1% xylocaine, 10 ml

•   General anesthesia may be required for infants and uncooperative children.

Instruments

•   22 G, 20 cm long needle with stilet

•   20 ml syringe

•   50-100 ml of urografin 60%.

Procedure

   1.  Sonographic guidance.

   2.  Choose calyx to be punctured.

   3.  Puncture should be laterally as possible, through renal parenchyma.

   4.  Puncture chosen calyx under screening guidance with
22 G needle.

   5.  Check position of needle tip within the pelvicalceal system.

   6.  Remove stilette of needle.

   7.  Aspirate urine with a 20 ml syringe.

   8.  Measure volume of urine aspirated.

   9.  Urine may be sent for bacteriology, cytology, chemistry.

10.  Inject urografin through the needle, under US monitoring. Total volume of urografin injected should be less than the volume of aspirated urine.

11.  Withdraw the needle.

12.  Shift patient to the fluoroscopy site.

13.  Radiographs of the opacified renal collecting system various position, including delayed errect films.

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Imaging percutaneous intrabdominal pelvic abcess drainage

IMAGING PROCEDURE

Percutaneous Intraabdominal/
Pelvic Abscess Drainage

Objective

In cases of suspected intraabdominal abscess:

•   Diagnostic aspiration of intraabdominal fluid collections for microbiologic diagnosis

•   Drainage of postoperative/spontaneous abscesses

•   Drainage of liver/visceral abscesses

•   Prevent impending rupture of visceral abscesses.

Patient Preprocedure Preparation

•   Blood prothrombin time

•   Antibiotic cover if required

•   Fasting for 6 hours

•   Surgical cleaning and draping of the site of drainage.

Position

Supine and related to location of abscess.

Anesthesia

•   IV sedation with diazepam

•   Local infiltration analgesia with 1% xylocaine 10 ml

•   General anesthesia may be required for infants and uncooperative children.

Instruments

•   18 G, 20 cm long needle with stilet (Fig. 22.1)

•   0.035" or 0.038" diameter, 100 cm long J-shaped guidewire

•   Sterile surgical blades

•   Graded teflon dilators 7F-12F

•   Drainage catheter 8F-12F. Pigtail with multiple holes; or Malecot catheter/Sump drainage catheter with needle-introducer

•   Suture and needle for fixation of catheter

•   Adhesive tape

•   Connector (Fig. 22.2)

•   3-way stopcock (Fig. 22.3)

•   Negative suction bag (Romovac)

•   Biopsy needle (Fig. 22.4).

Procedure

   1.  Patient positioned according to location of abscess, such that puncture site is easily accessible.

   2.  Sonographic or CT guidance.

   3.  Puncture site chosen under sonographic/CT guidance with 18 G needle.

   4.  Follow needle till its tip is well inside the abscess cavity. Remove stilet of needle.

   5.  Aspirate 2-5 ml of fluid; store in sterile vial for microbiologic analysis.

   6.  Pass guidewire through needle. Check position of guidewire within abscess cavity.

   7.  Stab incision along needle tract.

   8.  Remove cannula of needle.

   9.  Dilate tract to one size above catheter size.

10.  Place catheter in abscess cavity over guidewire.

11.  Remove guidewire.

12.  Connect catheter to negative suction collection system.

13.  Suture catheter and skin wound.

14.  Secure catheter to skin with adhesive tape.

Postprocedure

1.  Flush abscess cavity with antibiotic saline periodically.

2.  Remove catheter when drainage stops completely.

Alternative Technique

1.  This technique is suitable for larger fluid collections, and requires an experienced operator.

2.  Local analgesia.

3.  Stab incision at site.

4.  Use needle/introducer/catheter assembly, e.g. pigtail catheter/Malecot catheter/Sump catheter.

5.  Insert assembly through stab incision, and direct toward abscess cavity.

6.  When needle tip is well inside the cavity, withdraw needle-introducer, leaving catheter in cavity.

7.  Aspirate some fluid for bacteriologic diagnosis.

8.  Connect catheter to negative suction system and follow remaining steps as above.

Complications

Hemorrhage.

Any questions be sent to drmmkapur@gmail.com   

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