Is Ultrasound-guided Bedside Percutaneous Transhepatic Biliary Drainage Safe and Feasible in Critically Ill Patients with Severe Cholangitis? A Preliminary Single-center Experience

HIGHLIGHTS

This study highlights the utility of bedside ultrasound or USG-guided PTBD as a technically feasible and safe procedure with an acceptable clinical outcome in patients who are critically ill with biliary obstruction and severe cholangitis where biliary drainage is imperative.

INTRODUCTION

Presently, the majority of the biliary drainage is performed through the endoscopic approach. Despite technical advancements and improved therapeutic expertise, the endoscopic approach may not be feasible, necessitating PTBD. Common indications of PTBD include failed endoscopic retrograde cholangiopancreatography (ERCP), hilar obstruction, or altered anatomy due to prior entero-biliary surgery.¹ Acute severe cholangitis secondary to obstructive biliopathy needs special mention. Such patients are critically ill and often require admission to the ICU.² Unless managed expeditiously, severe cholangitis poses high mortality.^3,4 In addition to systemic antibiotic therapy and other ICU management, severe cholangitis due to biliary obstruction requires urgent biliary drainage. Percutaneous transhepatic biliary drainage plays a crucial role in such a situation.⁵ Many of the patients with acute severe cholangitis are on mechanical ventilation which makes their shifting difficult and risky. Endoscopic biliary drainage may not be feasible in these critically ill patients. Furthermore, most of the centers, particularly in developing countries lack ERCP facilities and expertise as well as the facility of the fluoroscopic suite. These logistic and patient-related issues may cause a delay in biliary drainage that results in the worsening of the sepsis. Bedside USG has become an essential component of intensive care management for diagnostic and interventional procedures, thus bedside percutaneous drainage seems to be a more feasible option in such critically ill patients.⁶

Ultrsound-guided bedside biliary drainage is a minimally invasive procedure in the setting of cholangitis and may act as a salvage procedure that will allow rapid biliary decompression.^7–9 This study aims to evaluate the practical feasibility of bedside USG-guided PTBD (USG-PTBD) and to establish its initial safety and efficacy in patients with severe acute cholangitis due to obstructive biliopathy.

MATERIALS AND METHODS

A single-arm observational retrospective study was performed after approval from the institutional scientific and ethical committee. Patients with acute severe cholangitis who underwent bedside USG-PTBD in the ICU between September 2020 and September 2021 were consecutively included. Patients with incomplete data were excluded. Finally, a total of 20 patients comprised the study cohort.

Tokyo’s guidelines 2018 were followed to diagnose and assess the severity of acute cholangitis in patients with obstructive biliopathy.¹⁰ All patients received intravenous antibiotics and other supportive measures on a case-to-case basis. Bedside PTBD was planned only when a patient could not be shifted to a fluoroscopic suite. The failure to mobilize the patients outside the ICU was due to unstable conditions, ongoing mechanical ventilation/impending need for mechanical ventilation, or continuous requirement of ionotropic support, as assessed by the attending intensivist.

RESULTS

The demographic and baseline characteristics of the patients are summarized in Table 1. A total of 20 patients underwent bedside PTBD, including 13 male and 7 female patients. The mean age of the cohort was 50.5 years, ranging from 34 to 70 years.

Gall bladder malignancy (45%, n = 9) was the most common etiology of biliary obstruction, followed by cholangiocarcinoma (25%, n = 5). Among 20 patients, proximal obstruction was found in 55% (n = 11) of patients and primary biliary confluence was occluded in 65% (n = 13) of patients. All the patients had features of severe sepsis at the time of PTBD with median total leucocyte counts of 22.92 × 10⁹/L. Six of the patients were on mechanical ventilation during the procedure. The mean total and direct bilirubin of the cohort were 18.21 ± 6.12 and 11.4 ± 3.92 mg/dL, respectively.

Technical success was achieved in all the patients. Left-sided PTBD was done in 40% (n = 8) of patients while 35% (n = 7) of patients underwent right-sided PTBD. The remaining 25% (n = 5) had bilateral PTBDs. The overall mean number of liver punctures attempted to access the biliary tree was 1.75 (1.21 for the left and 1.58 for the right lobe). All of the left-sided PTBDs were done through the segment 3 duct while most of the right-sided PTBDs were performed through the segment 6 duct. A total of 25 PTBD catheters were used, including ten 8 F and fifteen 10 F catheters. Initially, all the patients were kept on external drainage catheters. A total of 13 patients were discharged from the ICU; among them, 8 were still on external drainage at the time of the last follow-up while 5 underwent internalization. None of the patients had any major procedure-related complication although three patients developed transient hemobilia (minor complication) and one developed a small subcapsular hematoma. However, none of them required any further intervention. The catheter was displaced from the original position (noted on serial bedside abdominal radiograph) in five patients (three left and two right PTBDs). All of them required catheter repositioning without any need for additional biliary puncture (Table 2).

DISCUSSION

Biliary obstruction can occur due to various malignant and benign pathologies. Common one includes gall bladder carcinoma, cholangiocarcinoma, pancreatic adenocarcinoma, and metastatic disease, all of which have a poor prognosis. Biliary obstruction from any cause poses a risk of acute cholangitis due to biliary stasis. Unless expeditiously managed, acute severe cholangitis leads to septic shock and multiorgan failure, leading to death. It warrants prompt biliary decompression along with systemic antibiotics therapy and other supportive measures.^1–3,14 Currently, endoscopic biliary drainage is the standard treatment for biliary obstruction; however, the proximal obstruction may not be amenable for drainage through the endoscopic approach. Additionally, in the setting of severe cholangitis patients need continuous organ support and monitoring that requires different types of supportive equipment, connected with multiple lines/tubes. Thus, it is practically not a simple task to shift the patient into the fluoroscopic or ERCP suite. Furthermore, there is generally a shortage of round-the-clock trained manpower, particularly gastroenterologists and digital subtraction angiography (DSA) lab staff. All these factors often delay biliary decompression in critically ill patients. In such a situation, USG-PTBD may be a more suitable option and may improve the clinical outcome. Data regarding the feasibility and effectiveness of bedside PTBD using USG alone are limited. This study included twenty patients with acute severe cholangitis admitted to ICU who underwent USG-PTBD at the bedside. The technical success rate was 100%. 65% of patients improved clinically and got discharged from the ICU. Despite urgent bedside PTBD, 35% of patients died in ICU. All of them had a multiorgan failure and refractory shock at the time of PTBD. This emphasizes the need for early biliary decompression in patients with severe cholangitis before refractory shock and multiorgan failure supervene. Of note, none of the patients had major procedure-related complications. Although three patients had transient haemobilia and one had a small subcapsular hematoma, none of them required any further intervention.

A USG-guided bedside drainage is a well-established approach in critically ill patients. Ultrsound-guided biliary puncture has also been described in the literature.^15–20 In patients with minimally dilated USG helps to access the target duct. Even in a non-dilated system, USG offers the advantage of a peripheral portal vein-oriented puncture with an increased success rate, reducing the procedure and fluoroscopic time.²¹ Further, the additional use of Doppler imaging helps in differentiating a vessel from the biliary tree and increases the chances of safe entry into the bile ducts.^16,18 A study by Nennstiel et al. demonstrated a comparable technical success between fluoroscopic-guided PTBD and USG-PTBD.²⁰ Interestingly, major complications were observed only in the case of fluoroscopic-guided PTBD; however, all USG-PTBDs were left-sided while all fluoroscopic-guided PTBDs were right-sided.²⁰ We had two patients with minimally dilated ducts (4 mm) in whom PTBD was successfully placed under USG guidance. Besides the advantage of no radiation exposure, USG-PTBD does not utilize iodinated contrast. Contrast material per se causes chemical cholangitis, and contrast administration increases the intraductal pressure, leading to bacteremia. Thus, USG-PTBD also reduces the risk of flaring up cholangitis.²² Giurazza et al. demonstrated a high technical and clinical success rate of USG-PTBD with a low radiation dose.¹⁷ The overall mean number of liver punctures to access the biliary tree was 1.57 by Giurazza et al. However, our study had a slightly higher mean number of punctures (1.75). The latest small series (n = 10) by Gupta et al. also illustrated that bedside PTBD using USG alone is a safe and technically feasible procedure in critically ill patients.¹⁹

Our study had a few limitations. There could be operator bias as all the procedures were performed by a single interventional radiologist. The associated comorbidities, organ failure, and timing of PTBD in relation to the onset of organ failure were not recorded which could have influenced the clinical outcomes. Additionally, the follow-up period was short, including only the ICU course. Therefore, multicentric prospective cohort studies with larger sample sizes are required to further validate our findings.

In conclusion, USG-PTBD at the bedside is a technically feasible procedure with an acceptable clinical outcome in patients with biliary obstruction and severe cholangitis. In a critically ill situation where biliary drainage is imperative, bedside USG-PTBD seems to be a salvage option.

ORCID

Jitender Singh https://orcid.org/0000-0002-1784-0925

Tara Prasad Tripathy https://orcid.org/0000-0003-3763-9089

Ranjan Patel https://orcid.org/0000-0003-4780-5810

Karamvir Chandel https://orcid.org/0000-0002-7175-5203

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