ORIGINAL ARTICLE ABSTRACT. Introduction. Lopamudra Ghosh, Partha Pratim Samui, Debashis Dakshit

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1 INTERNAL-EXTERNAL VS EXTERNAL PERCUTANEOUS TRAN- SHEPATIC BILIARY DRAINAGE IN MANAGEMENT OF MALIGNANT INOPERABLE BILIARY OBSTRUCTION - A RETROSPECTIVE STUDY Lopamudra Ghosh, Partha Pratim Samui, Debashis Dakshit De partm e ntofradio-diagnos is, Me dicalco le ge Kolk ata, India. ORIGINAL ARTICLE : ABSTRACT BACKGROUND: Cas e s diagnos e d w ith m alignantbiliary obs truction are ofte n advance d and inope rable atth e tim e ofpre s e ntation and th e re fore carry a ve ry poor prognos is. Le s s is k now n about th e role ofpe rcutane ous trans h e patic biliary drainage (PTBD) in m anage m e nt ofth is patie ntpopulation. In available lite rature th e re is inade q uate data re garding com parative analys is ofinte rnal-e xte rnaldrainage (IED) and e xte rnaldrainage (ED) PURPOSE: To portray e fficacy ofptbd in m anage m e ntofm alignantbiliary obs truction and com pare be tw e e n ED alone and com bine d IED re garding outcom e. METHODS: Tw e nty cas e s ofbiliary drainage (12 cas e s ofed and 8 cas e s of IED) done at our ins titution w e re re tros pe ctive ly re vie w e d and re as s e s s e d ove r a pe riod of6 m onth s be tw e e n Fe bruary 2014 and July 2014 by clinicaland bioch e m icale valuation on day 7,14 and 28 afte r proce dure. RESULTS: Maxim um num be r of patie nts (9 ;45% ) w e re in th e ir 6th de cade. Outof20 patie nts 14 w e re fe m ale (70% ), 6 w e re m ale (30% ). According to e tiology ga lbladde r carcinom a w h ich w as diagnos e d in 6 cas e s (30% ) w as com m one s tofa l. Th e re w e re 1 faile d atte m pt(5% ), 3 cath e te r e xpuls ions (15% ) fo low ing ED and 1 proce dure re late d biliary s e ps is (5% ) afte r IED. On fo low up s e rum bioch e m icalm ark e rs cam e dow n to de s ire d le ve l(2m g/dl) approxim ate ly w ith in a w e e k in cas e ofied and tw o w e e k s afte r ED. Clinicalim prove m e nt w as als o re m ark ably be tte r in IED group. Ch e m oth e rapy w as initiate d in 5 patie nts (25% ) fo low ing IED and 3 patie nts (15% ) afte r ED afte r 1 w e e k. CONCLUSION: IED is m uch be tte r th an ED alone in te rm s ofm ore rapid clinicaland bioch e m icalim prove m e nt, cath e te r pos itionals tability, e as y acce s s to future s te nting and e arly initiation ofch e m oth e rapy. Keywords: biliary obs truction, e xte rnaldrainage, ga lbladde r carcinom a, inte rnal-e xte rnaldrainage Introduction Malignantbiliary obs truction com m only re s ults from various caus e s s uch as ga lbladde r carcinom a, ch olangiocarcinom a, pancre atic carcinom a, pe riam - pu lary carcinom a, m e tas tatic dis e as e s e tc. Cas e s atth e tim e of pre s e ntation are ofte n advance d and inope rable. Mos t ofth e s e cas e s carry a ve ry poor prognos is and le ads to lim ite d life e xpe ctancy of patie nts. 1 In th is group w ith obs tructive jaundice tre atm e ntby PTBD can alte r ove ra lm anage m e nt, provide s afe and e ffe ctive m e th od ofpa liation and im prove th e ir q uality of life. 2,3 Pe rcutane ous trans h e patic biliary drainage (PTBD) is a th e rape utic proce dure th at cons is ts of s te rile puncture of a pe riph e ra ly locate d biliary radicle unde r im age guidance fo low e d by place m e ntof a cath e te r or s te nt for inte rnalor e xte rnaldrainage ofbile. 4 W h e n cath e te r tip is k e pt proxim alto th e obs truction in orde r to drain bile outs ide body ofth e patie ntinto a bag, itis ca le d ED Correspondence : Dr. Lopam udra Gh os h De partm e ntofradio-diagnos is, Me dicalco le ge Kolk ata, 88, Co le ge Stre e t, Kolk ata , India. Te l.no: Em ail: drs am ilo@ re diffm ail.com Subm itte d 13 April2015, Acce pte d 27 April2015 PAKISTAN J OU RNAL OF RAD IOLOGY 13

Figure 1: A. Pre proce duralmrcp s h ow ing dilate d biliary radicle s (w h ite arrow ) and com m on bile duct(curve d arrow ) in a cas e of pe riam pu lary carcinom a B.

2 (Fig. 1). On th e oth e r h and during IED obs truction is cros s e d fo low e d by de ploym e nt of PTBD cath e te r into duode num acros s am pu la to drain bile both inte rna ly into gut and e xte rna ly into bag (Fig. 2). Adve ntofptbd be ing a m inim a ly invas ive proce dure h as re volutioniz e d m anage m e nt of patie nts w ith inope rable biliary m alignancy by de com pre s s ing th e biliary s ys te m. Figure 1: A. Pre proce duralmrcp s h ow ing dilate d biliary radicle s (w h ite arrow ) and com m on bile duct(curve d arrow ) in a cas e of pe riam pu lary carcinom a B. Exte rnaldrainage done by de ploying Pigtailcath e te r (black arrow ) proxim alto obs truction Figure 2: A. Pre proce duralmrcp s h ow ing h ilar obs truction (w h ite arrow ) by ga lbladde r carcinom a infiltration B. Inte rnal-e xte rnal drainage w as pe rform e d by de ploying PTBD cath e te r.cath e te r tip (black arrow ) note d in duode num biliary obs truction. Th e diagnos is w as m ade by clinical e xam ination and im aging by ultras ound (USG), contras te nh ance com pute riz e d tom ograph y (CECT), M RI and MRCP. A re tros pe ctive ch art re vie w w as pe rform e d us ing m ultidis ciplinary cas e note s ofth e s e patie nts w h o w e re re fe rre d for PTBD. Patie nts w ith m alignant inope rable biliary obs truction (m os tly proxim al), pre ope rative dis talbiliary obs truction (in cas e of gros s ly de range d LFT or biliary s e ps is ) or faile d ERCP w e re include d in th is s tudy. Patie nts h aving dis talope rable biliary obs truction, ble e ding diath e s is, m as s ive as cite s, contras th ype rs e ns itivity w e re e xclude d. In cas e of pre proce durale vide nce ofbiliary s e ps is w e did notpe rform IED as atte m pt to cros s th e am pu la could caus e pe ritum oralinflam m ation or pancre atitis. 5 So, in th is group w e pre - fe rre d pe rform ing ED alone. Biliary drainage w as done us ing Ph ilips A lura Xpe r FD 20 DSA m ach ine and Ph ilips cle ar h ue 550 USG m ach ine. Firs tly USG guide d puncture of dilate d biliary radicalw as done by Ch iba ne e dle (18-21 G).Th e n contras t w as inje cte d unde r fluoros copy guidance for anatom ic de line ation ofth e intrah e patic biliary radicle s and localiz e th e le ve lofobs truction. 6 In cas e ofe xte rnaldrainage m e ta lic guide w ire w as introduce d fo low e d by s e rialdilatation ofth e tract via fas cialdilator. Fina ly pigtail(8 F/10F) cath e te r w as de ploye d ove r th e w ire (Fig. 3). W h ile pe rform ing inte rnal-e xte rnaldrainage th e crux ofour te ch niq ue w as to cros s th e obs truction by te rum o (033) w ire to re ach duode num fo low e d by introduction of 5F BM C cath e te r ove r th e w ire upto duode num. Th e n te rum o w ire w as e xch ange d by a s tiffw ire and BMC cath e te r w as re m ove d. Fina ly PTBD cath e te r w as de ploye d ove r th e s tiffw ire (Fig. 3). W e practice proph ylactic Th e purpos e ofth is s tudy w as to portray e fficacy of PTBD in m anage m e ntofm alignantbiliary obs truction and com pare be tw e e n ED alone and com bine d IED re garding outcom e. Materials and Methods Th is re tros pe ctive de s criptive s tudy w as pe rform e d atour ins titution ove r a pe riod of6 m onth s be tw e e n Fe bruary 2014 and July 2014 and include d 20 patie nts w ith h is topath ologicaldiagnos is ofm alignant Figure 3: A. Exte rnalbiliary drainage done in cas e ofh ilar obs truction (w h ite arrow ) B. Inte rnal-e xte rnalbiliary drainage done in a s im ilar cas e w ith h ilar obs truction. Cath e te r tip note d in duode num (black arrow ) 14

intrave nous antibiotic (ce ftriaxone 1 gm ) im m e diate ly be fore puncture.

Maxim um num be r ofpatie nts (n-9 ;45% ) w e re in th e ir 6th de cade. O utof20 patie nts 14 w e re fe - m ale (70% ), 6 w e re m ale (30% ).

(n-2;10% ) (Fig. 4). Tw e lve patie nts (60% ) unde rw e nt ED and re s t8 (40% ) w e re s ubje cte d to IED.

3 intrave nous antibiotic (ce ftriaxone 1 gm ) im m e diate ly be fore puncture. 1 Results Tw e nty patie nts include d in th e s tudy w e re in th e age group ranging from 40 to 70 ye ars (m e dian-55 ye ars ). Maxim um num be r ofpatie nts (n-9 ;45% ) w e re in th e ir 6th de cade. O utof20 patie nts 14 w e re fe - m ale (70% ), 6 w e re m ale (30% ). Mos tcom m on m alignancy in th is s tudy w as ga lbladde r carcinom a (n- 8;40% ), fo low e d by pe riam pu lary carcinom a (n- 6;30% ), ch olangiocarcinom a (n-4;20% ), m e tas tatic dis e as e s (n-2;10% ) (Fig. 4). Tw e lve patie nts (60% ) unde rw e nt ED and re s t8 (40% ) w e re s ubje cte d to IED. Th e re w e re 1 faile d atte m pt(5% ) and 3 cath e te r e xpuls ions (15% ) fo low ing ED. Th e re w as no cath e te r dis lodge m e ntfo low ing IED. Proce dure re late d biliary s e ps is re s ulte d in 1 cas e (5% ) afte r com bine d drainage. Figure 5: Th e re is m ore rapid fa lofs e rum bilirubin fo low ing IED th an ED alone. Se rum bilirubin com e s dow n to approxim ate ly 2 m g/dlw ith in a w e e k fo low ing IED. in th e form ofre lie ffrom pruritus and s ym ptom s (alte - re d s e ns orium ) due to h e patic e nce -ph alopath y in com bine d approach rath e r th an ED alone. IED facilitate d an e arly initiation of ch e m oth e rapy w ith rapid corre ction of jaundice as m os t ch e m o- th e rapy protocolre q uire s a s e rum bilirubin le ve lof 2 m g/dl. Ch e m oth e rapy w as s ucce s s fu ly initiate d in 5 patie nts (25% ) fo low ing IED and 3 patie nts (15% ) afte r ED afte r 1 w e e k. As obs truction w as alre ady cros s e d during inte rnale xte rnaldrainage s cope for furth e r s te nting w as e as ie r. W e us e d s e lf-e xpanding nitinolm e ta lic s te nt in 3 cas e s of IED (Fig. 6). W e pre fe r us ing m e tal s te nts be caus e th e y h ave h igh pate ncy rate, s h orte r h os pitals tay and ove ra lle s s cos t th an plas tic s te nts. 7,8,9,10 Figure 4: A-Ge nde r dis tribution ofcas e s B-Age dis tribution ofcas e s C-Ove ra ldis tribution ofcas e s according to e tiology Fo low up w as done by clinicale valuation and e s tim ation ofs e rum bilirubin and s e rum alk aline ph os - ph atas e on day 7, 14 and 28. Me an s e rum bili-rubin de cre as e d from 18.5 m g/dlto 2 m g/dl(89 % re duction) m e as ure d 1 w e e k afte r IED. Me an s e rum bilirubin droppe d from 17 m g/dlto 10 m g/dl(41% re duction) m e as ure d afte r s am e pe riod fo low ing ED. Th us de s ire d le ve l(us ua ly < 2 m g/dl) ofs e rum bilirubin w as ach ie ve d w ith in 1 w e e k in cas e ofied. 5 Ittook alm os t 2 w e e k s for s e rum bilirubin to com e dow n to s am e le ve lafte r ED (Fig. 5). Th e re w as s im ilar tre nd of fa lof s e rum alk aline ph os ph atas e in th is tw o m e th ods. Th e re w as s ignificantclinicalim prove m e nt Figure 6: A. Pre -s te nting im age in cas e ofh ilar obs truction (w h ite arrow ) by ga lbladde r carcinom a s h ow s contras topacifie d biliary s ys te m. B. Se lfe xpandable m e ta lic s te nt(black arrow ) place d afte r bypas s ing h ilar obs truction. De s pite of s o m any advantage s th e re w e re fe w draw back s. IED w as bitcos tlie r, re q uire d fluoros copy 15

4 guidance and te ch nicale fficie ncy. On th e oth e r h and ED w as re lative ly ch e ap and w as a s im ple te ch niq ue w h ich could be done only unde r USG guidance. (Tab. 1) s h ow s e ffe ctanalys is ofied vs ED. Biliary infe ction w h ich is a dre adfulpe riope rative com plication in patie nts w ith m alignantobs tructive jaundice w as obs e rve d in 1 cas e fo low ing IED. 11 Th is w as re s olve d on tre atm e ntw ith antibiotic. Se rum bilirubin re duction afte r 1 w e e k Early re lie ffrom pruritus, alte re d s e ns orium IED IED 89 % 41% ye s Ste nting 3 (15% ) nil Ch e m oth e rapy afte r 1 w e e k 5 (25% ) 3 (15% ) Cath e te r e xpuls ion nil 3 (15% ) Biliary s e ps is (pos tproce dure ) 1 (5% ) nil Discussion Table 1: Effe ctanalys is ;IED vs ED PTBD h as be e n practice d ove r 40 ye ars w ith various te ch nicalm odifications and im prove m e nts. 12 Te ch nical s ucce s s ofth is proce dure is re porte d as m ore th an 9 0% and clinicals ucce s s as m ore th an 75% in lite - rature. 13 Th e re s ultofour s tudy re ve ale d th at th e re w as s trong fe m ale pre dile ction ofm alignantbiliary obs truction. Ga lbladde r carcinom a w as th e com - m one s te tiology fo low e d by pe riam pu lary carcinom a. Patie nts w ith ga lbladde r cance r w e re probably be tte r pa liate d by PTBD be caus e ofth e ir poor s urvival. 14 In cas e ofh igh h e patobiliary obs -truction trans h e patic biliary de com pre s s ion re m ains th e only re s ort be caus e itis inacce s s ible to e ndos copy guide d biliary inte rve ntions. 15,16,17 IED w as s upe rior to ED in te rm s ofm ore rapid clinicaland bioch e m icalim prove m e nt. Th e re w as e ve n cath e te r pos itionals tability, e as y acce s s to furth e r s te nting and e arly initiation of ch e m oth e rapy in cas e ofinte rnal-e xte rnalgroup. IED w as little cos tlie r, re q uire d h igh yie ld te ch nicalfacilitie s w h e n com pare d to ED. Butth e re w as ce rtainly ove ra l be tte r pos tproce duraloutcom e ofied in pa liation ofm alignantbiliary obs tructions. Conclusion PTBD is a s afe, cos t-e ffe ctive and m inim a ly invas ive pa liative te ch niq ue th atoffe rs a las ting s olution or no atle as tte m porary re lie f in patie nts w ith advance d irre s e ctable m alignantbiliary obs truction and im prove th e ir q uality oflife. IED is s upe rior to ED in te rm s ofm ore rapid clinical and bioch e m icalim prove m e nt, cath e th e r pos itional s tability, e as y acce s s to furth e r s te nting and e arly initiation ofch e m oth e rapy. References Ch e rian Ge orge, Olive r Rich ard Byas s, Jam e s Edm und Ian Cas t,inte rve ntionalradiology in th e m anage m e ntofm alignantbiliary obs truction,w orld J Gas trointe s to ncol ;2(3): Ke vin O. Clark e, M D, and Law re nce D. W agm an, MD, FACS,A Safe and Effe ctive M e th od ofpa liation, J SupportO ncol2006;4: Abrah am NS, Bark un JS, Bark un AN. Pa liation ofm alignantbiliary obs truction: a pros pe ctive trial e xam ining im pact on q uality oflife. Gas trointe s t Endos c 2002;56: Quality Im prove m e ntguide line s for Pe rcutane ous Trans h e patic Ch olangiograph y, Biliary Drainage, and Pe rcutane ous Ch ole cys tos tom y W ae le. A. Saad, MD, Mich ae lj. W a lace, MD, Joan C. W ojak, M D, Sanjoy Kundu, M D, and Joh n F. Carde la, M D, J Vas c Inte rv Radiol2010;21: Anne M. Cove y, M D, and K are n T. Brow n, M D, Pa liative Pe rcutane ous Drainage in M alignant Biliary O bs truction, J Support O ncol2006;4: K aude JV, W e ide nm ie r CH, Age e O F. De com - pre s s ion of bile ducts w ith th e pe rcutane ous trans h e patic te ch nic. Radiology ;93: Stok e r J, Lam e ris JS, van Blank e ns te in M. Pe rcutane ous m e ta lic s e lf-e xpandable e ndopros - th e s e s in m alignanth ilar biliary obs truction. Gas - trointe s tendos c ;39:

5 8. 9. H aus e gge r K A, Th urnh e r S, Bode ndörfe r G, Z o lik ofe r CL, Uggow itz e r M, Kugle r C, Lam m e r J,AJR Am J Roe ntge nol. Tre atm e ntofm alignant biliary obs truction w ith polyure th ane -cove re d W a ls te nts ;170(2): PinolV, Cas te ls A, Bordas JM, e tal. Pe rcutane ous s e lf-e xpanding m e tals te nts ve rs us e ndos copic polye th yle ne e ndopros th e s e s for tre ating m alignantbiliary obs truction: random iz e d clinicaltrial. Radiology 2002;225(1): Sm ith, R. H e paticoje junos tom y w ith trans h e patic intubation. Brit. 7. Surg ;57: W arre n, K. W., McDonald, W. M. Facts and fiction re garding s tricture s of e xtrah e patic bile ducts. Ann. Surg ;159: K aas s is M, Boye r J, Dum as R, e t al. Plas tic or m e tals te nts for m alignants tricture ofth e com m on bile duct?re s ults of a random iz e d pros pe ctive s tudy. Gas trointe s tendos cop 2003;57(2): Ch uan Xu1, Pe ng-h ua Lv1, Xin-En H uang2 *, Ling Sun1, Sh u-xiang W ang1, FuAn W ang, Inte r- nal-exte rnalpe rcutane ous Trans h e patic Biliary Drainage for Patie nts w ith M alignanto bs tructive,as ian Pac J Cance r Pre v, 15(21): Arne r O, H agbe rg S, Se ldinge r SI. Pe rcutane ous trans h e patic ch olangiograph y: puncture ofdilate d and non dilate d bile ducts unde r roe ntge n te le - vis ion control. Surge ry 19 62;52: van De lde n O M, Lam éris JS,Pe rcutane ous drainage and s te nting for pa liation ofm alignantbile ductobs truction, JS, Eur Radiol M ar;18(3): Jarnagin W R, Burk e E, Pow e rs C, Fong Y, Blum gartlh. Intrah e patic biliary e nte ric bypas s provide s e ffe ctive pa liation in s e le cte d patie nts w ith m alignant obs truction at th e h e patic duct conflue nce. Am J Surg ;175: M olnar W, Stock um AE. Re lie f of obs tructive jaundice th rough pe rcu tane ous trans h e patic cath e te r--a ne w th e rape utic m e th od. Am J Roe ntge nolradium Th e r NuclMe d Oct;122(2): PA KI S TAN JOURNAL O F R A DIOLO G Y 17

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