Interventional procedures in hepatobiliary system

Interventional procedures in Hepatobiliary system

1.Oncologic therapeutic procedures :Tumor Embolization : Method that

promotes tumor destruction by embolization of its suppliers vessels.◦ Hepatic radioembolization

Tumor Ablations : Percutaneous local tumor destruction by using a device to cause cell death.

2.Vascular Interventions

Trans-jugular intra hepatic portosystemic shunt (TIPS)

Transjugular liver biopsy (TJLB)

3.Biliary interventions :Percutaneous or endoscopic (ERCP)Percutaneous transhepatic

cholangiography (PTC)Percutaneous transhepatic biliary

drainage (PTBD)Percutaneous cholecystostomy (PC)

4.Others

Percutaneous liver biopsyUltrasound guided CT guidedPercutaneous collections drainage Ultrasound guided CT guided

Liver Cancer Treatments

Tumors need a blood supply, which they actively generate, to feed themselves and grow.

In treating cancer patients, interventional radiologists attack the cancer tumor from inside the body without medicating or affecting other parts of the body by using embolization and radiofrequency heat.

Chemoembolization delivers a high dose of cancer-killing drug (chemotherapy) directly to the organ while depriving the tumor of its blood supply by blocking, or embolizing, the arteries feeding the tumor.

In treating cancer patients, interventional radiologists use embolization to cut off the blood supply to the tumor (embolization), deliver radiation to a tumor (radioembolization), or combine this technique with chemotherapy to deliver the cancer drug directly to the tumor (chemoembolization).

Chemoembolization is a minimally invasive treatment for liver cancer that can be used when there is too much tumor to treat with radiofrequency ablation (RFA), when the tumor is in a location that cannot be treated with RFA, or in combination with RFA or other treatments.

Using imaging for guidance, a tiny catheter up the femoral artery in the groin into the blood vessels supplying the liver tumor.

ChemoembolizationThe embolic agents keep the

chemotherapy drug in the tumor by blocking the flow to other areas of the body. This allows for a higher dose of chemotherapy drug to be used, because less of the drug is able to circulate to the healthy cells in the body.

Chemoembolization is a palliative, not a curative, treatment. It can be extremely effective in treating primary liver cancers, especially when combined with other therapies.

Catheter is placed via a transfemoral approach with tip within the selected hepatic artery

SIR-Sphere size is small enough to gain entry into tumor nodules but too large to

pass through the end capillary bed into the venous circulation

SIR-Sphere size is small enough to gain entry into tumor nodules but too large to

pass through the end capillary bed into the venous circulation

Tumor vessels 25μm -75μmEnd arterioles 8 μmSIR-Spheres mean diameter 35 μm

Yttrium-90 Radioembolization

Radioembolization is very similar to chemoembolization but with the use of radioactive microspheres. This therapy is used to treat both primary and metastatic liver tumors.

This treatment incorporates the radioactive isotope Yttrium-90 into the embolic spheres to deliver radiation directly to the tumor. Each sphere is about the size of five red blood cells in width.

These beads are injected through a catheter from the groin into the liver artery supplying the tumor. The beads become lodged within the tumor vessels where they exert their local radiation that causes cell death

This technique allows for a higher, local dose of radiation to be used, without subjecting healthy tissue in the body to the radiation.

Radioembolization is a palliative, not a curative, treatment-but patients benefit by extending their lives and improving their quality of life. It is a relatively new therapy that has been effective in treating primary and metastatic liver cancers. It is performed as an outpatient treatment.

TIPS

Portal hypertension condition in which the normal flow of blood through the liver is slowed or blocked by scarring (cirrhosis) or other damage (e.g. hepatitis). Patients with the condition are at risk of internal bleeding or other life-threatening complications. Transjugular intrahepatic portosystemic shunt (TIPS) formation is a minimally-invasive treatment to alleviate this impaired blood flow.

Indications1. Prevention of variceal bleeding2. Acute bleeding of esophageal varices

that is refractory to medical therapies3. Esophageal variceal rebleeding4. Bleeding from gastric varices5. Prevention of bleeding from portal

hypertensive gastropathy 6. Ascites due to cirrhosis7. Budd-Chiari syndrome8. Veno-occlusive diseases

Absolute contraindications

1. Congestive heart failure2. Multiple hepatic cysts3. Uncontrolled systemic infection

or sepsis4. Unrelieved biliary obstruction5. Severe pulmonary hypertension.

Relative contraindications

1. Hepatoma2. Obstruction of all hepatic veins3. Portal vein thrombosis4. Thrombocytopenia of less than

20,000/cm(3)5. Severe coagulopathy6. Moderate pulmonary

hypertension

TIPS• A catheter is placed in the

right jugular vein

• The catheter is threaded through the superior and inferior vena cava to the hepatic vein

• Wall of the hepatic vein is punctured and the needle is directed across an approximate 2 inch gap to the portal vein

• Successful passage into the

portal vein is determined by the pattern of dye injected through the catheter

TIPS

• A guide wire is threaded through the needle to maintain the passage between the hepatic and portal veins

TIPS

• A balloon may be used across the passage to widen the holes in the vessel walls and the passage through the liver tissue

Biliary interventions :Percutaneous or endoscopic (ERCP)Percutaneous transhepatic

cholangiography (PTC)Percutaneous transhepatic biliary

drainage (PTBD)Percutaneous cholecystostomy (PC)

There is a 5-15% incidence of retained stones after cholecystectomy

Associated with increased risk of recurrent biliary obstruction, pancreatitis, and cholangitis.

Benign/malignant strictures.

ERCPThe diagnostic procedure of choice for abnormalities of the biliary and pancreatic ducts offers options of intervention:Stone extractionSphincterotomyPlacement of stents

A side viewing endoscope is advanced into the descending duodenum the papilla of Vater is identified and cannulated contrast is injected to visualize the pancreatic duct and biliary duct systems

Causes for ERCP failure include:Upper GI stricture/stenosisComplete ductal obstruction

limiting retrograde fillingPostsurgical biliary-enteric fistulaTechnical failure

MRCP is an effective alternative when ERCP is unsuccessful

Percutaneous Transhepatic CholangiographyOld reliableAccurate technique for defining the

site of obstructionProvides option of tissue biopsy and/or

intervention with drain or stentHas been largely replaced by non-

invasive techniques

Indications

Failed ERCP / ERCP not feasible (e.g. patients with gastrojejunostomy)

Biliary system delineation in presence of intra and extrahepatic biliary calculi

To identify obstructive cause of jaundice; and differentiate from medically treatable cause

Anatomic evaluation of complications of ERCP

Delineating bile leaks

Contraindications

Bleeding diathesisGross ascites

Technique◦Standard technique: Thin needle

puncture in ninth or tenth intercostal space

◦Contrast injected during slow withdrawal of the needle under fluoroscopic guidance

◦When duct placement confirmed, additional injection

◦Films taken in AP, right and left oblique

Surgical resection offers potential for cure but is rarely possible

Palliation alternatives:

1. Surgical bypass2. Percutaneous drainage3. Endoscopic or percutaneous

stent placement

Three types of drains:External – does not cross obstruction, drains percutaneously

Internal-external – bile in obstructed segment enters through the side holes of the catheter and emerges beyond the obstruction; the external segment can be capped

Internal – drains only into enteric system

Percutaneous cholecystostomy 

Image-guided placement of drainage catheter into gallbladder lumen. This minimally invasive procedure can aid stabilization of a patient to enable a more measured surgical approach with time for therapeutic planning.

Indications

poor surgical candidate/high risk patients with acute calculous or acalculous cholecystitis.

unexplained sepsis in critically ill patients (Diagnostic for cholecystitis as etiology of sepsis if clinical improvement after cholecystostomy).

access to or drainage of biliary tree following failed ERCP and PTC.

Contraindications

Absolute contraindicationsusually noneRelative contraindicationsbleeding diathesis: all attempts should

be made to correct coagulopathy.ascitesgallbladder tumor that might be

seededgallbladder packed with calculi

preventing catheter insertion

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