Biliary System interventions

Over the past few decades, biliary interventions have evolved a great deal. Opacification of the biliary system was first reported in 1921 with direct puncture of the gallbladder. Subsequent reports described direct percutaneous biliary puncture. The technique was revolutionized in 1960s with the introduction of fine-gauge (22- to 23-gauge) needles.

During the 1970s, percutaneous biliary drainage (PBD) for obstructive jaundice and percutaneous treatment of stone disease was introduced.[1, 2] Percutaneous cholecystostomy was first described in the 1980s. With the advent of metallic and plastic internal stents, further applications in the treatment of biliary diseases were developed.

Current percutaneous biliary interventions include percutaneous trans hepatic cholangiography (PTC) and biliary drainage to manage benign[3] and malignant obstruction and percutaneous cholecystostomy. Percutaneous treatment of biliary stone disease with or without choledochoscopy is still performed in selected cases. Other applications include cholangioplasty for biliary strictures, biopsy of the biliary duct, and management of complications from laparoscopic cholecystectomy and liver transplantation.

This article outlines the procedure for percutaneous biliary drainage.[4] For descriptions of other biliary interventions, see Percutaneous Cholecystostomy,Percutaneous Cholangiography, and Biliary Stenting.

In many cases, percutaneous trans hepatic cholangiography (PTC) is followed by the placement of percutaneous biliary catheters for drainage. Percutaneous biliary drainage (PBD) is needed in many patients. For example, it may be helpful in relieving obstructive symptoms, especially those due to un re sectable malignant tumors (see the image below), as well as in treating those with various types of benign strictures (including postoperative strictures), primary sclerosing cholangitis and liver transplants.[5]

Obstruction of the common bile duct in a patient with pancreatic carcinoma.

Other indications include cholangitis secondary to biliary obstruction, diversion for bile leaks while the patient is awaiting surgery, and transhepatic brachytherapy for cholangiocarcinoma.

Nowadays, endoscopic retrograde cholangio pancreatography (ERCP) is the mainstay of therapy for the above conditions, with percutaneous biliary drainage being reserved for conditions in which ERCP fails or is not available.

Contraindications for percutaneous biliary drainage include the following:

  • Massive ascites


  • Multiple intrahepatic obstructions


  • Bleeding diathesis

Alternatives to standard drainage

 Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an effective alternative for biliary drainage after a failed endoscopic retrograde cholangiopancreatography (ERCP).[36] EUS-BD can be divided into three different techniques as follows:

  • EUS-ERCP rendezvous technique


  • EUS-guided ante grade biliary drainage


  • EUS-guided transluminal biliary drainage Complications of percutaneous drainage are most frequent in cases of malignant obstruction. In addition to complications of percutaneous trans hepatic cholangiography (PTC), bile leakage, bilorrhea, hemobilia, cholangitis, hemothorax, and pancreatitis can develop. For more information on the complications of PTC, see Percutaneous Cholangiography.
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