17

Percutaneous Biliary
Drainage:
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Technical and Catheter-

Related Problems in 200 Procedures

Peter A. Mueller1 Analysis of 200 consecutive percutaneous biliary drainages revealed critical techni-
Eric vanSonnenberg cal and clinical components not previously emphasized. In this series, successful
Joseph T. Ferrucci, Jr. drainage was achieved in 1 88 (94%) of 200 instances, and 67 (36%) of the 1 88 patients
were discharged from the hospital without formal surgical exploration. Severe acute
periprocedural complications occurred in 1 6 (8%) of the 200 procedures (death, three
cases; septicemia, seven; and bleeding, six). Minor periprocedural complications oc-
curred in 39 (20%) of the 200 instances (postprocedural fever, 21 ; hemobilia, 18).
Significant delayed in-hospital complications with catheter function occurred in 22% of
procedures (postclamping cholangitis, 36; catheter leaking eight). In outpatients under
chronic catheter care, complications including inadvertent catheter disbodgment, tube
obstruction, and cholangitis occurred at least once in most patients. Details of the
etiology, prevention, and management of these major and minor complications are
outlined.

Previous reports from this and other institutions have documented the effec-
tiveness of percutaneous biliary drainage for relief of biliary obstruction [1-5].
Until recently, however, limited case experience has not permitted critical analysis
of the various technical and clinical problems that may occur during the proce-
dure or during aftercare of the drainage catheter system as percutaneous biliary
drainage becomes more widely applied and more difficult cases are attempted,
the technical complexities encountered consistently exceed available descrip-
tions in the literature. In an attempt to bridge this gap, we are supplementing our
initial report of the first 62 cases undergoing percutaneous biliary damage in this
hospital [1 ] by reviewing procedural details and complications in our present total
experience of 200 procedures through June 1 981.

Materials and Methods

Percutaneous biliary drainage was performed on 200 occasions in 1 88 patients. Final
diagnoses were: pancreatic cancer, 1 08 (54%) of 200 procedures; periportal metastasis
(colon, breast, lung), 36 (1 8%); carcinoma of bile duct or gallbladder, (1 3%); failed biliary
enteric bypass, 1 3 (7%); benign stricture, eight (4%); and common duct stone nine (4%).
The indications for biliary drainage were primary palliative drainage, 1 08; preoperative
decompression (benign and or malignant), 68; sepsis, 25; failed biliary enteric bypass, 15;
and stricture dilatation five. Some patients were drained for more than one indication (e.g.,
jaundice and sepsis).
Received July 6, 1981; accepted after revision Successful insertion of either an external or internally draining catheter was carried out
September 21, 1981.
in 108 (94%) of the 200 procedures. Internal drainage was achieved in 144 (72%) of 200
All authors: Department of Radiology, Massa- and external catheter drainage in 44 (22%).
chusetts General Hospital, Harvard Medical
Pancreatic cancer was the most common diagnosis (108 [54%] of 200). In 51(50%) of
School, Boston, MA 02114. Address reprint re-
quests to P. R. Mueller.
the 108, biliary drainage was the primary palliative therapy; 42 of the 108 were drained
preoperatively for 3-7 days. All patients undergoing preoperative decompression were
AJR 138:17-23, January 1982
0361-803X/82/1381-0017 $00.00 allowed to drain externally even if the catheter had been negotiated through the obstructing
© American Roentgen Ray Society lesion.
 18 MUELLER ET AL. AJR:138, January 1982

TABLE 1: ComplIcations of Percutaneous Biliary Drainage 1 0 or more punctures of the liver with an 1 8 gauge needle.
One patient suddenly bled about 500 ml via the drainage
No. Patients (n 188)
catheter on the 3 days after the procedure [1 ]. This was
Acute:
caused by a side-hole positioned outside the bile duct lumen
Death 3
Bleeding 6 in the hepatic parenchyma, allowing communication with a
Sepsis 7 major vascular channel. After repositioning, the catheter
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Fever 21 bleeding ceased.

Hemobilia 18 Varying amounts of hemobilia were also demonstrated by
Delayed (in-hospital):
Postclamping cholangitis
injection of the biliary catheter in 1 8 other patients (fig. 1).
21’
Cholangitis with multiple seg- In these cases, blood casts were often visible in the bile
mental obstructions 15 duct but no direct biliovenous communications were shown.
Leaking around catheter 8 Since blood casts may obstruct the bile ducts and/or the
No. Patients/No. Episodes
Delayed (outside hospital):f drainage catheter, one or two irrigations with 10 ml of
Dislodgment 11/28 normal saline are performed each hour in these patients for
Cholangitis 13/20 a 1 2-24 hr period. Within this interval, the clots are lysed
Tube obstruction 7/14
and drainage of bile ensues.
This is of the last 33 patients who underwent clamping.
Follow-up data available on 40 of 67 patients discharged.

Delayed Complications
Of 1 08 patients who had an external or internal drainage proce-
dure, 67 were discharged from the hospital. Accurate follow-up was In-hospital. An unsuccessful attempt at conversion to
obtained in 40 patients. Ofthe rest 66 were drained for preoperative internal drainage by clamping a properly positioned catheter
decompression (malignant or benign disease), 37 died in the hos- was the most common delayed in-hospital complication.
pital for reasons not directly related to their drainage, three died as This was manifested by cholangitis (fever, chills) and oc-
a result of the drainage, and 1 5 patients underwent insertion of a
curred in 21 (63%) of the last 33 patients who underwent
permanent biliary endoprosthesis. Of the 67 patients discharged,
clamping of a properly positioned internal drainage tube.
51 had malignant disease; the average survival in this group was
The cholangitis was treated by unclamping the tube and
less than 7 months. Sixteen of the 51 patients survived 7 months or
longer. Of these, two had a diagnosis of adenocarcinoma, presum- again placing the catheter to external drainage. After the
ably in the pancreas, and were alive and well 7 months after patient’s condition stabilized, the original catheter was re-
drainage. The rest had metastases to periportal nodes from a variety placed with a larger (1 0-1 2 French) polyvinyl argyl tube
of sites, including lung (three), breast (two), colon (one), renal cell (Brunswick Co. , St. Louis, Mo.) with multiple side-holes and
carcinoma (one), lymphoma (one), hepatoma (one), metastatic ad- then reclamped. The incidence of cholangitis upon reclamp-
enocarcinoma (two), and carcinoma unknown primary (three). All ing after exchange for the larger catheter decreased to
patients with periportal metastases were treated with a combination 11%.
of chemotherapy and/or irradiation. In 1 5 patients who had undergone adequate right-sided
drainage, cholangitis developed unrelated to tube clamping
Results or tube manipulation. All of these patients had tumors in-
volving the common hepatic duct as well as segmental
Complications are listed in table 1 as either acute or obstruction of the left and right systems. Ten of these
delayed. Delayed complications are subdivided into in-hos- patients had a left-sided percutaneous biliary drainage to
pital and postdischarge complications. decompress a presumed infected system. Response to bi-
lateral drainage is difficult to define. None of this group of
1 5 patients survived more than 1 2 weeks. Five of 1 0 with
Acute Complications
bilateral catheters became afebrile. The rest had periodic
Death. Three patients died from complications directly episodes of cholangitis. Two of the other five had only a
related to percutaneous biliary drainage. Of these, two died single episode of cholangitis and responded to antibiotic
from bleeding believed to result from 1 0 or more punctures treatment. The other three had recurrent episodes of cho-
of the liver with an 1 8 gauge sheath needle. One patient Iangitis.
with severe emphysema sustained a pneumothorax and A less common complication, leakage of bile around the
bilious pleural effusion that led to his death. catheter insertion site, occurred in eight procedures (3%).
Sepsis and fever. Seven patients had frank septic epi- In three cases, the cause was a malpositioned catheter
sodes (severe hypotension and positive blood cultures). All (side-holes below the area of obstruction); three patients
of these had infected bile or were febrile prior to the drain- had ascites; in two, there was no discernible cause.
age. There was transient fever in 21 patients after catheter Outside hospital. Various degrees of catheter dysfunction
insertion, but it required no specific additional therapy. will occur in any patient who maintains a drainage catheter
Bleeding and hemobilia. There was clinically apparent for an extended period of time (over 2-3 months).
internal bleeding (greater than 500 ml) in six patients, two Of the 67 patients discharged from the hospital, follow-up
of whom died. Only one of the other four required emer- data were difficult to obtain in 20 because they were dis-
gency surgery; the rest were treated with fluids and blood charged to other states or chronic care facilities. Compli-
products. All were technically difficult procedures, requiring cations in the other 40 are divided into the number of
 AJR:138, January 1982 PERCUTANEOUS BILIARY DRAINAGE 19

Fig. 1 .-Hemobilia complicating catheter in-

sertion. A, Cholangiogram immediately after inser-
tion of percutaneous drainage catheter. Elongated
intraductal filling defects represent clotted blood
(arrows). No direct venous communication evi-
dent. B. 48 hr later. Clear ducts indicate complete
lysis of clot. Appearance of drainage changed
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from bloody to clear during interval.

A B

patients and number of episodes because many patients nique is to localize the anteroposterior orientation of the bile
were seen more than once for the same complication (table ducts by turning the patient into a lateral position. If the
1 ). Types of complications included catheter occlusion by patient is thin and cooperative a straight lateral approach
bile encrustations, debris, or tumor (seven of 40), catheter can be made. Hawkins [1 1 ] designed a long 22 gauge
disbodgment (1 1 ), and cholangitis (1 3). Perhaps more inter- needle over which a 4 French sheath is placed for a single
esting is the fact that the actual number of significant com- puncture method of percutaneous drainage. If an appropri-
plications was large if individual episodes are considered. A ate duct is entered during the fine needle cholangiogram,
total of 62 complications was treated in the 40 individuals the needle acts as a guide wire and the sheath is advanced
followed closely. However, the frequency of complications over the needle into the duct. We have used this method on
appeared to correlate with the degree of family and home occasion, but find the excessive length and flexibility of the
nursing care received by individual patients. 22 gauge needle to be cumbersome. Another method to
In most cases, tube manipulations were performed on an reduce sheath needle punctures is to repeat the puncture
outpatient basis in less than 1 hr and were followed by a 3 of the opacified ducts with a 22 gauge needle directed at an
day course of broad-spectrum antibiotics. However, seven appropriate duct for drainage. If the correct duct for drain-
patients were readmitted for tube manipulations because of age is then entered, the larger sheathed needle can be
active cholangitis. In two cases, de novo catheter insertion inserted adjacent to the 22 gauge needle.
was required when attempts to replace a dislodged tube In general, while there are several useful methods to
were unsuccessful. One patient with an external drainage minimize the number of sheathed needle punctures per-
catheter who lived 7 months was seen on a biweekly basis formed, most cases require no more than two or three. If
for tube check and/or repositioning. Another external drain- the appropriate duct is not entered, reevaluation of the
age patient eventually formed a well epitheliazed biliary approach should be made and the methods described above
cutaneous fistula and the tube was removed completely to should be applied. One must be aware, however, that some
allow bile to drain directly into a colostomy-type bag. patients will require five to 1 0 punctures and the benefit of
continuing the procedure in such cases should be weighed
carefully against the increased risk of complications.
Discussion

While many articles in the literature have commented on

Acute Periprocedural Sepsis
both the technique andcomplications of percutaneous bili-
ary drainages, little has been written in the prevention and Severe septicemia (positive blood cultures with hyperten-
management of these problems [6-9]. sion) was relatively uncommon in our series (seven [3.5%]
of 200). Most of these patients and those who had only a
transient postprocedure fever (21 [1 0.5%]) were found to
Death and Bleeding
have infected bile.
Death (three instances) or significant bleeding (six) oc- While the latter was usually self-limited, severe septicemia
curred in nine (4.5%) of our 200 procedures. All were can be life-threatening and prevention is important. We have
technically difficult procedures with six of nine requiring 10 found that two-stage delayed internal drainage not only
or more punctures of the liver with an 18 gauge needle. This prevents severe septicemia but also increases the chances
correlates with the known severe complication rate of about of completing an internal drainage on patients who have a
3% that we reported earlier in a compilation of reports of technically difficult obstruction.
complications from large needle punctures [10]. The usual indications for a two-stage delayed approach
There are several methods that can be used to reduce included: (1) acute suppurative cholangitis, (2) marked duct
the number of punctures performed. The most fruitful tech- dilatation with uncertain location of the exact position of the
 20 MUELLER ET AL. AJR:138, January 1982

I
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Fig. 2.-Two-step conversion from external to internal drainage in patient initially ill with acute suppurative
cholangitis. A, Initial
placement of percutaneous drainage catheter (external) accomplished good external
drainage. Blood casts within both left and right hepatic ducts (arrows). B, 5 days later. Patient is afebrile and
bile ducts show considerable reduction in caliber. Blood casts have lysed and cleared. c. Conversion to internal
drainage.

residual lumen, and (3) exceptionally fragile or medically effectively corrected the sepsis initially in all cases but one.
unstable patients (fig. 2). By limiting manipulations in gravely However, the management of acute cholangitis following
ill patients to those required to gain catheter access to the tube clamping has been a difficult problem. Contrast injec-
bile ducts and establish external decompression only, acute tion after unclamping does not usually reveal the cause.
morbidity may be reduced without sacrificing subsequent Initial low-pressure injection of the catheter may show ‘ ‘side-

options. About one-third of our recent cases initially drained hole runoff’ ‘ with contrast material visualized only above the
externally were then successfully advanced to internal strictured area (fig. 3). Injection with greater pressure (al-
drainage at 3-5 days. However, the likelihood that success- though more dangerous for sepsis) may be required to
ful catheterization of the stricture would be accomplished demonstrate contrast material within the duodenum. On the
eventually could not be predicted on the basis of the initial other hand, removal of the catheter will not necessarily
cholangiographic appearance. reveal an obstructing sediment, plug, or debris.
Several factors may account for ‘ ‘ easier’ ‘ catheterization We believe the occurrence of cholangitis is actually re-
of the stricture at a delayed second sitting: (1 ) decreased lated to several contributing factors: (1 ) Placement of a
duct caliber above the obstruction straightens the course of catheter with a protruding external segment will lead to
the guide wire directing it into the strictured lumen; (2) colonization of the biliary tree with bacteria. Twenty-four
reactive edema at the site of obstruction may resolve; and hours after the initial drainage, all bile cultures will show
(3) development of a transparenchymal tract around the growth of a combination of organisms. Nevertheless, this in
catheter may facilitate use of a larger caliber and a more itself is not necessarily the cause of cholangitis. (2) There is
varied assortment of catheter types. In difficult cases, a considerable epithelial damage to the biliary tree created by
combination of a curved tip (Cobra visceral, Cl, C2, C3, insertion of a catheter. A denuded epithelium contaminated
Cook, Bloomington, Ind.) catheter together with a memory by bacteria is susceptible to cholangitis [1 2-1 5]. (3) Most
torque guide wire (Ring, 0.089 or 0.097 cm, Cook) may important is partial obstruction of the biliary duct, which may
allow circumferential searching by torque action until the be due to one or more of the following causes: (a) the
guide wire finds the residual lumen. The guide wire is never relatively small internal diameter of the commonly used 8.3
forced through the obstruction but is allowed to fall along French Ring pigtail biliary catheter (Cook); (b) the inability
the path of least resistance. of bile to gain entrance into the small side-holes of the 8.3
French Ring pigtail biliary catheter; or (C) an actual mechan-
ical obstruction created by the tube itself.
Delayed In-Hospital Complications
The end result is partial obstruction superimposed on a
Delayed in-hospital cholangitis occurred in 36 patients damaged and contaminated biliary duct system. The poten-
either after clamping a “well positioned” internal catheter tial of this combination has been clearly shown in animal
(21 patients) in an attempt to convert a patient to antegrade studies in which bacteria placed in unobstructed biliary
flow or in patients who had a segmental obstruction of the systems of dogs have no ill effects. However, when even
left hepatic duct, which was undrained (15 patients) (table partial obstruction is superimposed, cholangitis and death
1). Of the last 70 patients undergoing percutaneous biliary ensue [12-15].
drainage, conversion from external to internal drainage by It is also apparent that patients who drain a large quantity
tube clamping was attempted in 33 and failed in 21(63%) of ‘ duodenal contents” in the first few days may be more
of cases as a result of cholangitis. Prompt unclamping susceptible to postclamping cholangitis. Perhaps, retro-
 AJR:138, January 1982 PERCUTANEOUS BILIARY DRAINAGE 21
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A B
Fig. 3.-Real or pseudoobstruction? Cholangio- Fig. 4.-External drainage due to complete periportal obstruction produces unstable or insecure
gram taken when acute cholangitis occurred after catheter position due to ‘short purchase ‘; dislodgment is common. A, External drainage catheter
clamping appropriately positioned internal drainage with short purchase. Normal liver excursion during respiration may inadvertently retract catheter from
catheter. Contrast visualized only above structure may intraductal position. B, Metastatic carcinoma to portahepatis with complete duct obstruction. Short
be due to “side-hole runoff’ rather than true catheter purchase.
occlusion. Exchange of catheter for larger caliber is
required to correct relative obstruction to bile egress.

grade duodenal reflux is an indication of duodenal spasm French argyl catheter and were discharged with successful
and relative increase in intraluminal duodenal pressure and internal drainage. Two patients who had repeated episodes
hence further obstructs the egress of bile. of cholangitis were found to have diffuse tumor involvement
The most effective solution to the postclamping cholan- of the liver and may also have had selective ductal obstruc-
gitis problem is to perform an exchange of catheters by tion that contributed to the cholangitis.
inserting a 1 0 or 1 2 French polyvinyl (argyl catheter). These
catheters have relatively thin walls and the internal diameter
Delayed Posthospital Discharge Complications
of the 1 0 French caliber is 1 .6 times as large as the 8.3
French Ring pigtail catheter. Large side-holes may also be The most common chronic complication seen in the 40
cut manually and positioned under fluoroscopy to contribute patients who were closely followed after hospital discharge
to better drainage. Placement of a polyvinyl argyl catheter was dislodgment of the biliary drainage tube (table 1 ). This
is unfortunately not possible at the time of the initial drainage is also one of the major reasons for cholangitis in this group
because the tube is too soft and flexible. However, after the of patients. It is interesting that this occurred in both patients
initial drainage catheter has been in place for 5-7 days, a with ‘ ‘internal’ ‘ drainage catheters and ‘ ‘external. ‘ ‘There
sufficient transparenchymal tract is formed to allow ready appeared to be a correlation between the patients under-
insertion. Introduction of the argyl system is also facilitated standing the function of the catheter and need for proper
by use of a coaxial catheter technique (placement of the 10 catheter care and a lower incidence of disbodgment.
or 1 2 French argyl catheter over a 6 or 7 French polyeth- Recognition of the limitations of an external drainage
ylene catheter). The stiffening effect of the coaxial system catheter and the technical considerations in replacing a
aids placement of the soft argyl catheter. dislodged catheter are essential to preventing and managing
Further benefits derive from catheter exchange to the these two complications.
argyl polyvinyl system. Patients find the softer tube more When only external catheter drainage can be achieved
comfortable at the abdominal wall cutaneous opening. Be- because of complete obstruction in the mid-common duct
cause the argyl catheter is straight, it may be left in the or periportal region, catheter position is rarely secure and
distal common bile duct allowing the patient’s physiologic inadvertent disbodgment is not uncommon. In such cases,
sphincter at the choledochoduodenal junction to control length of catheter “purchase” within the biliary ducts may
egress of bile and obviate the potential problem of duodenal be minimal (e.g., 2-3 cm) and predispose to dislodgment
reflux. Also, catheters left in the distal common duct are less by simple body movements and respiratory excursions (fig.
likely to cause duodenal irritations and are protected from 4). One of our patients with an external drainage catheter
the degradation of catheter wall material that results from and an extremely short purchase experienced spontaneous
chronic exposure to stomach and duodenal secretions. dislodgment on six different occasions. Often the small
Of the 21 patients who failed initial tube clamping, 19 caliber of the intrahepatic duct radicle in which the catheter
were successfully treated by replacement with a 10-12 is situated in such cases requires a straight catheter (vs.
 22 MUELLER ET AL. AJR:138, January 1982

Fig. 5.-External drainage of obese patient

with high common duct obstruction from pan-
creatic cancer. A, Potential position of external
catheter may prevent easy withdrawal of catheter.
B, 8.3 French catheter in posterior branch of right
hepatic duct insures “longer” purchase.
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Fig. 6.-Direct replacement inadvertently dis-

lodged catheter. A, Curved tip catheter in skin
opening and torqued in cephalad (arrow) (skin
opening and origin of hepatic tract do not align
directly). Injection of contrast shows curved direc-
tion of tract, B, Guide wire inserted through cath-
eter and advanced along hepatic parenchymal
tract into duodenum,

pigtail) adding to the instability of catheter fixation. continuity, a curved tapered tip catheter (Cobra Cl , C2, C3)

An effective measure to improve catheter purchase in may be successfully negotiated into the liver and followed
such situations is to divert the catheter tip from the imme- with a guide wire (fig. 6).
diate vicinity of the obstruction and direct it into a more Nonoperative access to the biliary tree affords new op-
peripheral radicle of either the left or right hepatic duct (fig. tions for the clinical and radiobogic management of biliary
5). This maneuver places a longer length of catheter within tract obstruction. We believe the technical complexities of
the lumen of the biliary tree, significantly lengthening ‘ ‘ pur- percutaneous biliary drainage have been generally under-
chase.” stated in reports published to date. Despite the poor overall
Should the catheter be inadvertently dislodged, direct prognosis for many patients undergoing biliary catheter
reinsertion through the original cutaneous puncture site is decompression procedures, complications of initial punc-
often feasible. After 7-1 0 days of catheter drainage, a ture and subsequent catheter function are not uncommon
granulating transparenchymal track forms, usually 2 French and require knowledge, evaluation, and management, as
larger in caliber than the outer diameter of the catheter itself well as a commitment to long-term catheter aftercare by the
[1]. The tract will not seal over for 48-72 hr and can usually radiologist.
be reentered provided the cutaneous entry site can be lined
up with the entry point through the liver capsule.
ACKNOWLEDGMENT
Gordon et al. [16] recommended a fluoroscopically guided
contrast sinogram via a conical Christmas tree adapter We thank Ruth Brock for nursing care of these patients.
placed in the cutaneous entry site to aid in locating and
opacifying the transhepatic tract [16]. Guide wire/catheter
sytems are then inserted under direct vision. We prefer to REFERENCES
insert a sheath from an 18 gauge needle directly through 1. Ferrucci JT Jr, Mueller PR, Harbin WP. Percutaneous trans-
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wire. If the skin and liver puncture sites are not in direct Radiology 1980;1 35:1-13
 AJR:138, January 1982 PERCUTANEOUS BILIARY DRAINAGE 23

2. Nakayama T, Ikeda A, Okuda K. Percutaneous transhepatic sheath for decompression. Radiology 1979:131:252-253
drainage of the biliary tract. Gastroenterology 1978:74:554- 10. Harbin WP, Mueller PR, Ferrucci JT Jr. Complications and use
559 patterns of fine needle transhepatic cholangiography: a multi-
3. Pereiras R, Schiff E, Barbin J, Hutson D. Role of interventional institutional study. Radiology I 980:135:15-22
radiology in disease of the hepatobiliary system and pancreas. 11. Wissmer B. Cholangitis. In: Bockus HL, ed. Gastroenterology,
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