Placement of a nasobiliary drain during ERCP facilitates subsequent percutaneous transhepatic cholangiography

Background: The management of patients with complex biliary pathology often requires the combined efforts of biliary endoscopists and vascular radiologists. Percutaneous access with placement of stents or drains is often needed if endoscopic retrograde cholangiopancreatography (ERCP) fails to provide adequate biliary drainage. Percutaneous transhepatic cholangiography (PTC) is a safe and effective technique in experienced hands with a low overall morbidity and mortality. Nevertheless, PTC has its risks, including liver injury and bleeding, as the initial access to the biliary tree is obtained in a blind fashion. We describe the use of nasobiliary drains (NBDs) to facilitate PTC after ERCP. Methods/Results: Between 6/93 and 11/97, 9 patients who were identified during ERCP as requiring subsequent PTC, underwent NBD placement at conclusion of ERCP. Diagnoses included cholangiocarcinoma (5), postoperative biliary stricture (2), intrahepatic stone disease (If, and postoperative bile leak (1). Endoscopic stenting was attempted in 4/9 cases, but was unsuccessful due to acute angulation of the bile duct and/or inability to cross the stricture. Five of 9 patients had generalized intrahepatic ductal dilatation; in the remaining 4 patients, dilatation was focal or absent. NBDs were left in place for 4-76 hours (mean: 26 hours) and were well tolerated in all cases. At the time of PTC, a nasobiliary cholangiogram was obtained and the opacified biliary tree was targeted under direct vision using fluoroscopy. With this technique, access to the biliary tree could be obtained in all cases. No immediate complications were encountered. Conclusions: 1. Nasobiliary drain placement with subsequent NBD cholangiogram facilitates PTC and may be especially helpful in patients with decompressed/non-dilated intrahepatic bile ducts. 2. Prospective investigations are needed to confirm and quantify the benefit of this technique. 3. Placement of a nasobiliary drain should be considered when PTC is needed after ERCP.

Duke Scholars

Author Paul Vincent Suhocki Radiology, Interventional Radiology

Author Paul Simon Jowell Medicine, Gastroenterology

Author Malcolm Stanley Branch Medicine, Gastroenterology