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Treatment of malignant obstruction
Adjunct to surgery
Treatment of CBD calculi
Treatment of benign strictures
Diagnostic?
Failed ERCP
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WHO performance status
Imaging
Clinician/MDT discussion
Coagulation status
Ascites
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0 – 2.
In bed less than 50% of time
BSIR Audit report 2009, 19.8% in hospital
mortality
15.6% in hospital mortality for benign disease
Audit of my procedures, 18% 30 day mortality
Patients with lower WHO performance status
do better
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Ultrasound. Confirm biliary obstruction, mass,
metastatic disease, calculi
CT. Confirm level of obstruction, mass,
metastatic disease
MRI/MRCP. Complex biliary strictures, CBD
calculi, liver metastases
ERCP. May have failed
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Malignant or benign disease
Gastroenterologists
Surgeons
Radiologists
Other Healthcare Workers
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Surgical. ERCP and plastic stent or PTC and
Internal/External biliary drainage
Palliative. ERCP or PTC and metallic Stent
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ERCP treatment of choice
PTC and internal/external drain or plastic
stent. May enable successful ERCP later
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INR < 1.4. Consider vitamin K, FFP and also
Beriplex/Octaplex. Contain prothrombin
complex concentrate. Factors II, VII, IX and X
as well as Proteins C and S
Platelets > 100,000. If less, consider platelet
transfusion
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WHO performance status
Check coagulation
Explain procedure at least 1 day before
Risks. Bleeding, bile leak, infection,
pneumothorax and failure
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Anaesthetist
GA
Discuss need for airway protection
Use LA
When applying for consultant post ask what
access you may have to anaesthetics
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At start of procedure
Gentamicin 240 mg IV
Metronidazole 500 mg IV
Discuss with Microbiology
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Use what works best for you
Chiba needle 22 gauge
Trochar needle 18 gauge
NEF set
Stiff Terumo wire
Amplatz wire
Catheters. BMC and straight
Self expanding stent
Internal/External drains 8.5/10.5F. Discuss
with your surgeon
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Ascites present? Drain first
Ultrasound?
Right lobe. Mid axillary line. Aim for xyphisternum.
Left lobe. Locate with U/S and usually aim for
segment III.
Very gently inject 1/3 strength contrast (100) as needle
is withdrawn
Duct entered when contrast flows away from needle
and persists
Duct not entered. Change angle and try not to exit liver
capsule
Duct normally anterior to portal vein
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Pre-surgery for cholangiocarcinoma. Discuss
lobe to drain. Usually the lobe being preserved.
Pre-surgery for pancreatic cancer. Right lobe
puncture.
Palliative. Drain right, left or both?
1. Chiba needle to opacify ducts then choose
duct for trochar puncture and wire etc.
2. NEF set. Single puncture then wire, dilator
and access sheath
Consider bile for cytology if no diagnosis
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Stiff Terumo to cross lesion. Use pin vice for
torque
Straight catheter
Amplatz wire
Dilator
Stent/Drain
1 or 2 stage procedure?
Temporary drain following stent?
Plug track? Coils, gelfoam etc.
Technical success >95% (BSIR audit)
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Unable to cross stricture, establish external
drainage (8.5F internal/external drain). Further
attempt after decompression usually
successful.
Care with drainage bag essential.
Internal external drainage, try not to use bag
and bung catheter.
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In hospital mortality 19.8%.
Death or major complication 21.2% overall, 18.3%
benign, 21.7% malignant.
Major complications in 7.9%, haemorrhage 3.5%,
renal failure 1.8% and sepsis 1.6%.
Minor complications in 26.0%, pain 14.3%, sepsis
7.7% and haemorrhage 4.5%.
Association with ascites, elevated INR and low
platelets.
1 year survival <20% for malignant disease.
Drainage more effective if stents placed across
ampulla
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1. Further audit of this cohort is required to
determine cause of death and to demonstrate
whether or not there are significant associated risk
factors.
2. Given the high mortality in this group of
patients further data collection will be required.
Significant improvements in data completeness are
required. Data submission remains voluntary, but
NHS services should consider how they can make
resources available to support data collection for
individual operators
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86 yr female presented with sepsis and
subsequent jaundice
Arteriopath but otherwise reasonably fit
CT
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Abscess right lobe liver drained
Antibiotics
MDT discussion, for palliation
ERCP, failed to stent due to large duodenal
diverticulum
PTC
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69 yr male with obstructive jaundice
CT, operable mass in head of pancreas
MDT discussion
Surgical candidate
ERCP to place plastic stent failed
PTC
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75 yr female with obstructive jaundice
CT, large central liver mass, likely
cholangiocarcinoma. Further deposit in
segment II
MDT discussion, not operable, palliative
PTC and stent left lobe
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71 yr male
Metastatic colorectal cancer
Multiple liver resections
Jaundice with recurrent liver and peritoneal
tumour
Considering further chemotherapy
CT Small residual liver with mild duct
dilatation
ERCP failed
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59 yr female with inoperable
cholangiocarcinoma
Previous ERCPs with plastic and finally
recently metal stent into left lobe
Recurrent jaundice
?percutaneous options
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Careful patient selection after MDT discussion
“Appropriate” Anaesthesia
Try not to use external drainage bags