Peripheral portal vein-oriented non-dilated bile duct puncture for percutaneous transhepatic biliary drainage

Figure 1 A 57-year-old man who had undergone living donor liver transplantation with right posterior sectional graft 8 mo earlier presented with recurrent cholangitis due to stricture of the bilioenteric anastomosis. A: Computed tomography shows that the intrahepatic bile duct (BD) is not dilated. The arrow indicates a peripheral branch of B6; B: Under ultrasonographic guidance, a non-dilated peripheral branch of B6 is punctured along its running course with a 21-G needle; C: While controlling the needle tip, a 0.018-inch guide-wire (GW) is inserted carefully into the BD; D: When the hydrophilic 0.035-inch GW crosses the anastomotic stricture, a 7-Fr catheter with distal curve crosses the stenotic bilioenteric anastomosis and advances into the jejunal loop.

Figure 2 A 65-year-old man who had undergone segment 5 resection and radiofrequency ablation in segment 1 for hepatocellular carcinoma presented with bile leakage after surgery. A: Computed tomography shows non-dilated intrahepatic bile ducts and an intraperitoneal drainage tube (arrow) placed at the time of surgery; B: Cholangiogram via the endoscopic nasobiliary drainage tube (arrowhead) reveals stricture of the posterior sectional bile duct (arrow). Asterisk shows the intraperitoneal drain placed at the time of surgery; C: Non-dilated peripheral B6 (arrow) is punctured with a 21-G needle. Asterisk shows the intraperitoneal drain placed at the time of surgery; D: An 8-Fr biliary drainage tube is advanced through the strictured right posterior sectional bile duct and placed from B6 to the common bile duct.

Figure 3 This technique increased the possibility of the puncture needle crossing the targeted non-dilated bile duct, and also provided an appropriate angle to insert the drainage catheter for the next step. A: The insertion angle between the puncture needle and running course of the bile duct (BD) should be less than 30°; B: Under ultrasonographic guidance, percutaneous transhepatic puncture is performed along the running course of the targeted peripheral non-dilated BD (B6 for right-sided approach) or along the accompanying portal vein (P6) when the BD is not well visualized. This technique can provide an appropriate insertion angle of less than 30° between the puncture needle and BD running course.