Examination

Percutaneous Transhepatic Cholangiography with Biliary Drain Placement.

 

Clinical History

[Malignant] Intrahepatic Biliary Obstruction.

 

Operators:

Sarel Gaur MD

 

Medications:

Lidocaine 1%

IV Meds:

1 G of Ceftriaxone prophylaxis

 

Contrast:

[ ] ml of iodinated contrast intra-biliary

 

Fluoro time:

[ ] minutes

 

Access site(s):

Right distal biliary radical

 

Device(s):

Skater Biliary Drain 8F

 

Complications:

None

 

Procedure:

1. The procedure, possible complications, and the use of conscious
   sedation was explained to the patient informed consent was obtained. 

2. The patient was brought to the interventional radiology suite and placed supine.

3. The 10th rib interspace in the right midaxillary line was identified under fluoroscopy, and skin was marked.

4. The right hepatic lobe was
   visualized under ultrasound. 

5. The right abdomen was widely prepped with 2 percent chlorhexidine solution and draped.

6. Under constant ultrasound guidance, a Greb access needle was used to
   percutaneously access the biliary tree. Contrast study demonstrated proper placement of the needle within the biliary tree.

7. A microwire was then advanced through the needle and into the common right hepatic bile duct. Contrast injection revealed approach suitable for drain placement.

8. The needle was exchanged for a Greb introducer.  Greb sheath and Benson wire were manipulated into the common bile duct,

9. The common duct obstruction was crossed using an angled catheter and glidewire. Contrast injection confirmed access into the 3rd part of the duodenum.

10. The angled catheter was then exchanged for an 8 French by 40 cm internal/external biliary drain over an Amplatz wire.

11. Contrast study confirmed placement with opacification of the biliary tree and small bowel folds.

12. The catheter was then secured with 0 silk suture material and sterile dressing was applied.

13. The patient tolerated procedure well and there were no complications. 

 

Findings

Described in Procedure section.

 

Impression

Successful Internal/External Biliary Drain Placement.

 

Cholecystostomy Catheter Check

 

Date of procedure:

[ ]

 

Indication:

Cholecystostomy tube placed for acute cholecystitis.  For assessment of internal drainage and possible removal or replacement.

 

Operators:

Sarel Gaur MD

 

Medications:

None.

 

Contrast:

[ ] ml of Omnipaque intrapyelous

 

Fluoro time:

[ ] minutes

 

Access site(s):

RUQ

 

Device(s):

8F Pigtail drainage catheter, Cook Multipurpose

 

Complications:

None

 

Technique and Findings:

 

1. Informed Consent was obtained.

2. Patient was brought to the IR suite and placed supine on the table.

3. Contrast was attached to the catheter and injected while monitoring under fluoroscopy

4. There was opacification of the cystic duct, common hepatic duct, and common bile duct.  There was drainage identified going into the 2nd portion of the duodenum.

5. The catheter was cut and removed.

6. A sterile dressing was placed.

7. The procedure was terminated

Maximal Sterile Barrier Technique was used during CVC Insertion including:  Cap/mask/sterile gown/gloves/large sterile sheet. Hand hygiene/2 % chlorhexidine for cutaneous antisepsis

 

Impression:

Successful removal of the cholecystostomy tube.

Normal internal drainage of the biliary system.

 

Plan or Recommendations:

Dressing management.

 

 

Reporting Activities

 
 
Clinical History
 
 
Indication

 
Technique
 

 

1. The procedure, possible complications, and the use of conscious sedation was explained to the patient informed consent was obtained.

2. The patient was brought to the interventional radiology suite and placed supine.

3. The 10th rib interspace in the right midaxillary line was identified under fluoroscopy, and skin was marked.

4. The right hepatic lobe was visualized under ultrasound. Images of the dilated intrahepatic biliary tree were saved.

5. The right abdomen was widely prepped with 2 percent chlorhexidine solution and draped.

6. Under constant ultrasound guidance, a Greb access needle was used to percutaneously access the biliary tree, access into a right lower segment 5 or 6 biliary radicle. Contrast study demonstrated proper placement of the needle within the biliary tree.

7. A microwire was then advanced through the needle and into the proximal right-sided duct. Contrast injection revealed approach suitable for drain placement.

8. The needle was exchanged for a Greb sheath plus dilator. The dilator removed and eventually, a glidewire was used to access through the common bile duct. There is initial difficulty crossing through this region suggesting luminal narrowing.

9. Contrast injection confirmed access into the small bowel.

10. The greb sheath was advanced into the small bowel. 140 cm Amplatz was advanced through the sheath into the distal tip was coiled within the small bowel. A 8 French skater biliary drain was advanced over the wire. The wire was removed and the catheter was coiled with its distal tip within small bowel. The external portion of the drain was secured to the skin using a silk suture.

11. Contrast study confirmed placement with opacification of the biliary tree and small bowel folds, images were saved.

12. A sterile dressing was applied.

13. The patient tolerated procedure well and there were no immediate complications.

Technologist Comments 
 
Comparison
Findings
Moderate to severe intrahepatic biliary ductal dilatation.  
Common bile duct is not spontaneously opacified indicating intrinsic verses extrinsic obstruction.  
There is successful wire access through the common bile duct, region of obstruction.  
Final image documents the placement of the drain with the distal coil of the catheter within small bowel.  
 
Impression
Successful placement of a 8 French internal external biliary drain, access through a right lower lobe biliary radicle approach.  
Catheter is attached to gravity drainage bag.  
Please do not aspirate the catheter at the distal coil is within small bowel and could contaminate the biliary tree. Forward flushing only.