Left versus right-sided percutaneous transhepatic biliary drainage in relief of malignant obstruction

Musaib Ahmad Dar; Naseer Choh; Suhail Rafiq; Feroze Shaheen; Sadaf Ali; Irfan Robbani

doi:10.4103/MTSM.MTSM_9_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 4 | Issue : 4 | Page : 103-107

Left versus right-sided percutaneous transhepatic biliary drainage in relief of malignant obstruction

Musaib Ahmad Dar¹, Naseer Choh², Suhail Rafiq¹, Feroze Shaheen², Sadaf Ali³, Irfan Robbani²
¹ Department of Radiodiagnosis and Imaging, GMC, Srinagar, Jammu and Kashmir, India
² Department of Radiodiagnosis and Imaging, SKIMS, Srinagar, Jammu and Kashmir, India
³ Department of Surgical Gastroenterology, SKIMS, Srinagar, Jammu and Kashmir, India

Date of Submission	22-Apr-2020
Date of Decision	28-Apr-2020
Date of Acceptance	06-May-2020
Date of Web Publication	9-Oct-2020

Correspondence Address:
Dr. Suhail Rafiq
Department of Radiodiagnosis and Imaging, GMC, Srinagar, Jammu and Kashmir
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/MTSM.MTSM_9_20

Abstract

Background: Biliary tree obstruction and consequent jaundice occur in 70%–90% of these patients and have important consequences mainly for the patient's quality of life, morbidity, and overall mortality. Percutaneous transhepatic biliary drainage (PTBD) is an excellent palliative procedure to drain the bile ducts in malignant obstruction. We compared left- and right-sided approach in relief of malignant obstruction. The most common causes of malignant biliary obstruction (MBO) include pancreatic adenocarcinoma, hilar cholangiocarcinoma, ampullary/duodenal adenocarcinoma, gallbladder adenocarcinoma, lymphoma, and compressive metastatic peri-portal lymph node Materials and Methods: This study was a prospective, hospital-based study performed for 2 years from 2016 to 2018. PTBD was performed either through right in 16 patients or left approach in 15 patients. Two approaches were compared in terms of clinical and technological success, changes in laboratory data, internalization and survival. Results: (1) Rate of technological success was 100%. (2) There was a significant reduction in bilirubin, alanine transaminase (ALT), and alkaline phosphatase (ALP) levels after the procedure in both the approaches, but the decrease was more in the right-sided approach. Only the decrease in bilirubin levels was statistically significant. The decrease in albumin was attributed to the progression of the disease. (3) Clinical success was seen in 93.33% and 93.75% in left- and right-sided approach. (4) Internalization was done in 86.67% patients in the left-lobe approach, while as in right-lobe approach, it was done in 93.75% patients. Conclusion: PTBD causes a significant reduction in the bilirubin level, irrespective of the amount of liver drained or the type of drainage (external/internal). In our study, the reduction in bilirubin, ALT and ALP was more in the right-lobe approach. However, only reductions in levels of bilirubin were statistically significant.

Keywords: Alkaline phosphatase, alanine transaminase, bilirubin, percutaneous transhepatic biliary drainage

How to cite this article:
Dar MA, Choh N, Rafiq S, Shaheen F, Ali S, Robbani I. Left versus right-sided percutaneous transhepatic biliary drainage in relief of malignant obstruction. Matrix Sci Med 2020;4:103-7

How to cite this URL:
Dar MA, Choh N, Rafiq S, Shaheen F, Ali S, Robbani I. Left versus right-sided percutaneous transhepatic biliary drainage in relief of malignant obstruction. Matrix Sci Med [serial online] 2020 [cited 2023 Mar 30];4:103-7. Available from: https://www.matrixscimed.org/text.asp?2020/4/4/103/297638

Introduction

The most common causes of malignant biliary obstruction (MBO) include pancreatic adenocarcinoma, hilar cholangiocarcinoma, ampullary/duodenal adenocarcinoma, gallbladder adenocarcinoma, lymphoma, and compressive metastatic proximal lymph nodes.^[1],[2] The most common cause in our country is carcinoma of the gallbladder.^[3] Biliary tree obstruction and consequent jaundice occur in 70%–90% of these patients and have important consequences mainly for the patient's quality of life, morbidity, and overall mortality.^{[4],[5],[6],[7],[8]} Despite technological advances, only 20% of periampullary tumors are found to be resectable at the time of presentation due to their invasiveness, late symptom appearance, and onset in elderly people,^{[9],[10],[11]} and hence, effective palliation is the goal of the treatment.^[12],[13]

In recent years, endoscopic retrograde biliary drainage has overtaken percutaneous transhepatic biliary drainage (PTBD) as the initial procedure of choice in patients with distal bile duct obstruction.^[14],[15] PTBD is a procedure to drain the bile ducts in the presence of a blockage or damage that prevents normal bile drainage. It has been shown that even if only 30% of the liver parenchyma is drained, it provides adequate palliation to relieve jaundice and associated pruritus.^[16],[17]

Indications

Decompression of the dilated biliary tree due to malignant tumors,^[18] strictures^{[19],[20],[21]} primary sclerosing cholangitis, undergoing liver transplants
Diversion of bile leak.^[20],[22]
Transhepatic brachytherapy for cholangiocarcinoma
Interventions^[23] in form of stent placement across a stricture, stone extraction, etc.

Right versus left percutaneous transhepatic biliary drainage^{[19],[23],[24]}

The appropriate puncture site is chosen based on the status of primary confluence, secondary confluence, and atrophy of liver parenchyma. For asymmetric liver function (atrophy, portal vein abnormalities), more benefit will be derived from drainage of the better functioning lobe.

Advantages of right-sided drainage

Favorable anatomy for subsequent intervention
Larger drainage catchment
Less radiation exposure to operator during placement and subsequent PTBD changes.

Disadvantages of right-sided drainage

More painful for patient
More chances of accidental slippage due to constant motion of the drainage catheter in the intercostal space during respiration.^[24]

Advantages of left-sided drainage

Less painful (avoids intercostal nerves)
Less morbidity (avoids blood vessels)
Preferred in ascites (due to relatively less pericatheter leak of ascites)^[24]
More easily accessed and less likely for drain to fall out (better patient care).

Disadvantages of left-sided drainage

Difficult or impossible in cases of atrophic or a high-riding left hepatic lobe
More likely to access a central duct instead of a preferred peripheral approach
More radiation exposure to performer's hand.

Complications:^{[19],[21],[25],[26]}

Complications are divided into minor and major

Minor complications

Pericatheter leak (bile leak along catheter) is a frequently observed complication
Pain
Low-grade fever.

Major complications

Cholangitis
Hemobilia and sepsis
Hypovolemia: Electrolyte and fluid loss from the procedure can be substantial
Bile leakage, catheter dislodgment and wound infection
Pneumothorax and biliothorax
Death (1.7%).

Absolute contraindications^{[23],[26],[27]}

Uncorrected coagulopathy
Massive ascites.

Relative contraindications

Multiple intrahepatic obstructions
Multiple hepatic cysts.^[27]

Aims and objectives

To evaluate the usefulness of the left lobe versus right lobe PTBD in terms of:

Relief of malignant obstruction and symptoms of same
Changes in mean laboratory data.

Materials and Methods

This study was a prospective, hospital-based study done in SKIMS, Soura from 2015 to 2017.
PTBD was performed either through right (subcostal or intercostal) in 16 patients or left-ductal (sub-xiphoid) approach in 15 patients.

Planning of intervention

Imaging

Prior to the initiation of procedure, three-dimensional cross-sectional imaging, i.e., (computed tomography or magnetic resonance imaging ± magnetic resonance cholangiopancreatography) of patients were reviewed to help identify dilated ducts and/or the level of obstruction for the consideration of a target.

Laboratory analyses

Evaluation of the patient's coagulogram, liver, and kidney function was needed. Most patients need contrast administration for cholangiogram which can derange renal function.

Inclusion criteria

Patients with confirmed diagnosis of malignant obstructive jaundice who were surgically unresectable
Unresectable malignant tumor, biliary stricture with failed ERCP.

Exclusion criteria

Patients with severe coagulopathy
Patients with severe ascites
Refusal to participate in the study.

Patient preparation

The patients were asked to have nothing by mouth several hours before the procedure (≥4 h for conscious sedation) along with good intravenous access. Prophylactic antibiotics were started before the procedure along with conscious sedation with midazolam and fentanyl. Informed consent was taken from each patient. Monitoring of vital signs (blood pressure, pulse, and oxygenation status) was done during and after the procedure.

Analysis

Technical success, clinical success (decrease in serum bilirubin level of more than 20% relative to baseline within 1 week after catheter insertion), change in other laboratory parameters (bilirubin, alanine transaminase [ALT], alkaline phosphatase [ALP], and albumin) before and after intervention (7^th day), rate of internalization (catheter in the second part of the duodenum), and survival were compared in both groups.

Survival was calculated in days from the day of intervention until death or last follow-up was assessed.

Statistical analysis

The Chi-square test was used for the comparison of noncategorical variables which include sex, symptoms of the disease, and internalization. t-test was used for the comparison of pre- and post-intervention bilirubin levels, ALT, ALP, and albumin levels. The t-test for equality of means (Levene's test) was used to determine the age-distribution and to calculate mean survival rates in the two groups. The level of statistical significance was set at P ≤ 0.05.

Results

The age of patients ranged from 48 to 76 years with maximum number of patients in the age group of 55–65 years
There were about 53.3% males and 46.7% females in the left-sided approach. The corresponding figures in right-sided approach were 56.3% and 43.8%, respectively
The principle causes of jaundice in maximum number of patients were malignant obstruction due to GB carcinoma (35.48%), followed by hilar cholangiocarcinoma (32.25), metastases (22.58%), and pancreatic/periampullary carcinoma (9.67%) [Figure 1]
Rate of technological success (successful deployment of external/internal drainage) was 100%
Clinical success was seen in 93.33% (14/15) cases in left and 93.75 (15/16) cases in right-sided group
There was a significant reduction in bilirubin, ALT, and ALP levels after the procedure in both the approaches, but the decrease was more in the right-sided approach [Figure 2], [Figure 3], [Figure 4]. Only the decrease in bilirubin levels was statistically significant (P = 0.01)
There was a decrease in serum albumin level as well which was attributed to the progression of the disease
Internalization was done in 86.67% patients in the left-lobe approach [Figure 5], whereas in the right-lobe approach [Figure 6], it was done in 93.75% of patients
The mean survival rate was almost similar in the right-lobe approach (139.5 days) than in the left-lobe approach (137.7 days) [Figure 7].

Figure 1: Pie chart revealing the etiology of malignant obstructive jaundice

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Figure 2: Flouroscopic image revealing left-sided internal catheter. The distal end of the catheter is seen in the duodenum

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Figure 3: Fluoroscopic image revealed right-sided internal catheter within the duodenum

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Figure 4: Comparison between pre-and post-percutaneous transhepatic biliary drainage bilirubin levels

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Figure 5: Comparison between pre- and post-percutaneous transhepatic biliary drainage alanine transaminase levels

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Figure 6: Comparison between pre- and post-percutaneous transhepatic biliary drainage albumin levels

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Figure 7: Distribution of patients according to the survival in days

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Discussion

Technical success in the left group was 100% (15/15), and in the right group, it was 100% (16/16). In the study reported by Saluja et al.,^[28] the technical success achieved was 93% in the PTBD group. Better technical success in our study could be attributed to the advancement in micropuncture needles, guidewires, and catheters.

Percentage reduction change in bilirubin, ALT, ALP and albumin, pre-and-post PTBD was more in the right-sided approach as compared to the left-sided approach because 55%–60% of liver volume is drained by right hepatic duct while as only 35% of liver volume is drained by left hepatic duct. Reduction in bilirubin was attributed to the progression of underlying malignancy. Greater rate of internalization in right-sided approach is attributed to the fact right biliary duct is more in line with common hepatic duct and also because of the favorable angle between the two.

Conclusion

Our data support the fact that PTBD is an excellent procedure to drain the bile ducts in the presence of a blockage or damage that prevents normal bile drainage. Our results show that even though the survival of patients with MBO is dismal and most of the patients succumb to their illness, the survival of these patients can be enhanced significantly by subjecting them to biliary drainage, and the prognosis (survival) can be predicted in terms of their clinical and laboratory improvement. In our study, the reduction in bilirubin, ALT, and ALP was more in the right-lobe approach, but the decrease in albumin was more in the left-lobe approach. However, only reductions in bilirubin levels were found to be statistically significant. The decrease in albumin was attributed to the progression of malignant disease process. Our data also concludes that there is a significant decrease in symptoms after PTBD which is slightly more in the right-lobe approach than in the left-lobe approach.

PTBD causes a significant reduction in the bilirubin level, irrespective of the amount of liver drained or the type of drainage (external/internal). However, depending upon whether right or left-lobe approach is used, the outcome of the intervention in terms of clinical improvement, laboratory improvement, and complications varies.

Acknowledgments

The authors would like to thank the department of surgical and medical gastroenterology.

Financial support and sponsorship

SKIMS administration provided significant help in the form of free infrastructure.

Conflicts of interest

There are no conflicts of interest.

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