Percutaneous Biliary drainage / metallic stent insertion

Percutaneous biliary drainage (PBD) with metallic stent insertion is a minimally invasive procedure used to relieve biliary obstruction and restore bile flow in cases where the biliary system is blocked due to various conditions like strictures, tumors, or other causes.

Indications for Percutaneous Biliary Drainage and Metallic Stent Insertion

1. Biliary Obstruction: When there’s a blockage in the bile ducts due to gallstones, tumors, or strictures, causing symptoms like jaundice, pain, and fever.
2. Failed Endoscopic Drainage: In cases where traditional endoscopic methods like ERCP (endoscopic retrograde cholangiopancreatography) have been unsuccessful or are not feasible.
3. Preoperative Management: To alleviate symptoms and optimize patients with biliary obstruction before planned surgery, such as hepatic resection or pancreaticoduodenectomy.
4. Palliative Care: To relieve symptoms in patients with advanced malignancies causing biliary obstruction, improving quality of life.

Pre-procedure Preparation

1. Patient Evaluation:
   • Thorough assessment of the patient’s medical history, symptoms, laboratory tests (including liver function tests and bilirubin levels), imaging studies (such as ultrasound, CT scan, MRI), and coagulation profile.
   • Determination of the location, extent, and cause of the biliary obstruction.
2. Imaging Studies:
   • Use of imaging modalities like ultrasound, MRCP (magnetic resonance cholangiopancreatography), or CT cholangiography to visualize the biliary tree and identify the site of obstruction.
3. Informed Consent:
   • Explanation of the percutaneous biliary drainage and metallic stent insertion procedure, including its purpose, potential risks (like bleeding, infection, bile duct injury, stent-related complications), benefits, and alternatives. Obtaining informed consent from the patient.

Procedure Steps

1. Patient Positioning:
   • The patient is positioned on the procedure table, often lying on their back or slightly tilted to one side for better access to the biliary tree.
2. Local Anesthesia:
   • Administering local anesthesia to the skin at the puncture site (usually in the right upper quadrant of the abdomen) to minimize discomfort during the procedure.
3. Percutaneous Access:
   • Using imaging guidance (such as ultrasound or fluoroscopy), a thin needle is inserted through the skin and into the bile ducts to access the obstructed area.
4. Guidewire Placement:
   • A flexible guidewire is then passed through the needle and advanced into the bile ducts, beyond the site of obstruction, under fluoroscopic or ultrasound guidance.
5. Dilation and Catheter Insertion:
   • Over the guidewire, a series of dilators may be used to create a track for inserting the drainage catheter or metallic stent delivery system.
   • The drainage catheter is placed to allow bile to drain externally into a collection bag or internally into the duodenum, depending on the type of drainage needed.
6. Stent Insertion:
   • For metallic stent insertion, a specialized delivery system containing the stent is guided over the guidewire and positioned across the biliary obstruction.
   • The stent is then deployed, expanding to its designated size to maintain a patent pathway for bile flow through the obstructed segment.
7. Confirmation and Post-procedure Care:
   • Contrast material may be injected to confirm the proper placement of the stent and assess bile flow through the stent on fluoroscopy.
   • Post-procedure care involves monitoring the patient’s vital signs, pain levels, and potential complications like bleeding or infection. The puncture site is dressed, and appropriate pain management and follow-up instructions are provided.

Benefits and Clinical Outcomes

• Immediate Symptom Relief: Effective relief of symptoms related to biliary obstruction, such as jaundice, itching, and abdominal pain.
• Restored Bile Flow: Restoration of normal bile flow, which is crucial for digestion and waste elimination.
• Improved Liver Function: Reduction in elevated bilirubin levels and improvement in liver function tests.
• Palliation in Cancer Patients: Significant improvement in quality of life for patients with advanced cancers causing biliary obstruction, providing palliative care.

Risks and Complications

• Bleeding: Risk of bleeding at the puncture site or along the bile ducts.
• Infection: Possibility of infection, especially at the puncture site or in the biliary system.
• Bile Duct Injury: Rare risk of injury to the bile ducts during the procedure.
• Stent-related Complications: Potential for stent migration, blockage, or occlusion over time.

Post-procedure Care

• Monitoring: Close monitoring of vital signs, pain levels, and any signs of complications like bleeding or infection.
• Medication: Prescribing antibiotics or pain medications as necessary.
• Follow-up: Scheduling follow-up appointments to assess stent function, bile flow, and overall patient condition.

Percutaneous biliary drainage with metallic stent insertion is a safe and effective procedure for managing biliary obstruction and improving patient outcomes.