Cholestatic complications remain a primary cause of post-liver transplantation (LTX) morbidity in pediatric patients. Standard biliary access by endoscopic retrograde cholangioscopy may not be feasible due to modified biliary drainage. Percutaneous transhepatic biliary drainage (PTCD) may be performed alternatively. However, systematic data concerning safety and efficacy of PTCD in these patients are scarce.

In this retrospective study, procedural and safety characteristics of PTCD in pediatric patients following LTX were analyzed. We compared laboratory indicators of inflammation, cholestasis, and graft function before and at 6 and 12 months after the first PTCD insertion. Efficacy was analyzed by percentage of patients without cholangitis, need for surgical biliary re-intervention and re-transplantation during a follow-up period of 60 months.

Over a decade, PTCD was attempted in a total of 15 patients, with technical success (93.3%) in 14 patients. Periprocedural complications, including bleeding (7.1%) and cholangitis (21.4%) were observed in patients. During follow-up, both MELD-score (baseline: 13 [8-15] vs. 12 months: 8 [7-8], p<0.001) and parameters of cholestasis (GGT: baseline: 286 [47-458] U/L vs. 12 months: 105 [26-147] U/L, p=0.024) decreased. Prior to PTCD, cholangitis (64.3%) and cholangiosepsis (21.4%) were common complications. In contrast, following PTCD, cholangitis occurred in only one patient (7.1%). Five patients (35.7%) needed surgical biliary re-intervention and two (14.3%) required re-transplantation.

PTCD in pediatric patients following LTX had an acceptable safety profile, demonstrating a biochemical improvement of both cholestasis and graft function and may prevent cholestatic complications, thus reducing the need for surgical re-intervention and re-transplantation.

Special attention should be given to intra-abdominal adhesions in patients with a history of open cholecystectomy for gallstones or abdominal surgery. Choosing the appropriate surgical approach to remove the stones is crucial.

A 68-year-old male was admitted due to sudden onset of upper abdominal pain lasting more than 6 h. In 2018, he underwent open Billroth II surgery for gastric cancer at an external hospital, and in 2020, he underwent open cholecystectomy for gallstones. In August 2023, he received gamma knife treatment for recurrent gastric cancer brain metastasis at another hospital with good results. In December of the same year, the patient presented to our hospital due to recurrent common bile duct stones and cholangitis. Given his history of two abdominal surgeries, percutaneous transhepatic cholangiodrainage (PTCD) combined with choledochoscopic stone extraction was chosen, which was successful in completely removing the stones. A PTCD tube was left in place postoperatively.

For patients with a history of two or more abdominal surgeries who experience recurrent common bile duct stones, PTCD has the advantages of a shorter operative time, less blood loss, earlier postoperative ventilation, earlier resumption of eating, minimal trauma and faster recovery.

Interventional radiologists are an important part of a multidisciplinary team for the management of patients with biliary disease. Minimally invasive image-guided procedures can diagnose, temporize, and treat patients presenting with a broad spectrum of disease, including acute, chronic, benign, and malignant etiologies. In certain cases, interventional radiologists may provide definitive therapy for this often-difficult patient population. Effective treatment of patients with biliary disease is predicated on cooperation and collaboration of a multidisciplinary team working together providing optimal treatment to achieve positive outcomes.

Background and study aims Percutaneous transhepatic cholangioscopy (PTCS) is a management option for patients in whom peroral cholangioscopy or endoscopic retrograde cholangiopancreatography (ERCP) fail. We conducted a case series on the efficacy and safety of PTCS using a cholangiopancreatoscope cleared by the US Food and Drug Administration in 2020. Patients and methods Fifty adult patients scheduled for PTCS or other cholangioscopic procedure were enrolled at seven academic medical centers and followed for 30 days after the index procedure. The primary efficacy endpoint was achievement of clinical intent by 30 days after the index PTCS procedure. Secondary endpoints included technical success, procedure time, endoscopist ratings of device attributes on a scale of 1 to 10 (best), and serious adverse events (SAEs) related to the device or procedure. Results Patients had a mean age of 64.7±15.9 years, and 60.0% (30/50) were male. Forty-four patients (88.0%) achieved clinical intent by 30 days post-procedure. The most common reasons for the percutaneous approach were past (38.0%) or anticipated (30.0%) failed ERCP. The technical success rate was 96.0% (48/50), with a mean procedure time of 37.6 minutes (SD, 25.1; range 5.0-125.0). The endoscopist rated the overall ability of the cholangioscope to complete the procedure as a mean 9.2 (SD, 1.6; range 1.0-10.0). Two patients (4.0%) experienced related SAEs, one of whom had a fatal periprocedure aspiration. Conclusions PTCS is an important endoscopic option for selected patients with impossible retrograde access or in whom ERCP fails. Because of the associated risk, this technique should be practiced by highly trained endoscopists at high-volume centers. (ClinicalTrials.gov number, NCT04580940).

Biliary interventional procedures require physicians to track the interventional instrument tip (Tip) precisely with X-ray image. However, Tip positioning relies heavily on the physicians' experience due to the limitations of X-ray imaging and the respiratory interference, which leads to biliary damage, prolonged operation time, and increased X-ray radiation.

We construct an augmented reality (AR) navigation system for biliary interventional procedures. It includes system calibration, respiratory motion correction and fusion navigation. Firstly, the magnetic and 3D computed tomography (CT) coordinates are aligned through system calibration. Secondly, a respiratory motion correction method based on manifold regularization is proposed to correct the misalignment of the two coordinates caused by respiratory motion. Thirdly, the virtual biliary, liver and Tip from CT are overlapped to the corresponding position of the patient for dynamic virtual-real fusion.

Our system is respectively evaluated and achieved an average alignment error of 0.75 ± 0.17 mm and 2.79 ± 0.46 mm on phantoms and patients. The navigation experiments conducted on phantoms achieve an average Tip positioning error of 0.98 ± 0.15 mm and an average fusion error of 1.67 ± 0.34 mm after correction.

Our system can automatically register the Tip to the corresponding location in CT, and dynamically overlap the 3D virtual model onto patients to provide accurate and intuitive AR navigation.

This study demonstrates the clinical potential of our system by assisting physicians during biliary interventional procedures. Our system enables dynamic visualization of virtual model on patients, reducing the reliance on contrast agents and X-ray usage.

A variety of transhepatic percutaneous biliary procedures are appropriate for the treatment of pathologies of the biliary system.

The aim of this article is to describe best practices for performing percutaneous transhepatic cholangiography with placement of a biliary drain (PTCD), percutaneous transhepatic removal of bile duct stones, percutaneous stenting of the bile ducts, and percutaneous treatment of postoperative bilioma.

The authors reviewed existing literature on relevant current recommendations and presented them based on their own facility's approach.

Biliary interventions are mostly aimed at treating some form of cholestasis of benign or malignant etiology. The technical success rate is up to 90%.

Percutaneous biliary interventions are safe and effective procedures in the treatment of pathologies of the biliary system, preferably used when endoscopic access is not possible due to anatomical conditions.

This study aims to report a minimally invasive, percutaneous technique to cross complete biliary occlusions using a radiofrequency wire to create a biliary-enteric neo-anastomosis or biliary neo-duct.

All patients who underwent attempted creation of a neo-anastomosis/neo-duct using an RF wire were included in the study. Patients with non-malignant, complete and non-traversable biliary occlusion were considered for the creation of a neo-anastomosis (4 patients)/neo-duct (1 patient).

Five patients (4 females, 1 male) with a mean age of 40 years (range: 10-69 years) were included in this study. Percutaneous bowel access was obtained in three of five patients and a snare was placed in the jejunal loop to serve as a target for RF wire advancement. In two patients, an enteral target was provided using a peroral endoscope in collaboration with gastroenterology. The procedure was technically successful in all cases and no intra-operative complications occurred. Patency of the neo-anastomosis was maintained in all patients, with follow-up ranging from 4 to 11 months.

The RF wire was successfully used to create a biliary neo-anastomosis with a minimally invasive approach for the treatment of non-malignant complete biliary occlusion. This technique offers patients with complete biliary occlusion a safe, effective and durable treatment option which avoids the need for a permanent biliary drain and ultimately results in an improved quality of life.

Choledochoscopy, or cholangioscopy, is an endoscopic procedure for direct visualization within the biliary tract for diagnostic or therapeutic purposes. Since its conception in 1879, many variations and improvements are made to ensure relevance in diagnosing and managing a range of intrahepatic and extrahepatic biliary pathologies. This ranges from improved visual impression and optical guided biopsies of indeterminate biliary strictures and clinically indistinguishable pathologies to therapeutic uses in stone fragmentation and other ablative therapies. Furthermore, with the evolving understanding of biliary disorders, there are significant innovative ideas and techniques to fill this void, such as nuanced instances of biliary stenting and retrieving migrated ductal stents. With this in mind, we present a review of the current advancements in choledo-choscopy with new supporting evidence that further delineates the role of choledochoscopy in various diagnostic and therapeutic interventions, complications, limitations and put forth areas for further study.

Management of malignant bile duct obstruction is both a clinically important and technically challenging aspect of caring for patients with advanced malignancy. Bile duct obstruction can be caused by extrinsic compression, intrinsic tumor/stone/debris, or by biliary ischemia, inflammation, and sclerosis. Common indications for biliary intervention include lowering the serum bilirubin level for chemotherapy, ameliorating pruritus, treating cholangitis or bile leak, and providing access for bile duct biopsy or other adjuvant therapies. In some institutions, biliary drainage may also be considered prior to hepatic or pancreatic resection. Prior to undertaking biliary intervention, it is essential to have high-quality cross-sectional imaging to determine the level of obstruction, the presence of filling defects or atrophy, and status of the portal vein. High bile duct obstruction, which we consider to be obstruction above, at, or just below the confluence (Bismuth classifications IV, III, II, and some I), is optimally managed percutaneously rather than endoscopically because interventional radiologists can target specific ducts for drainage and can typically avoid introducing enteric contents into isolated undrained bile ducts. Options for biliary drainage include external or internal/external catheters and stents. In the setting of high obstruction, placement of a catheter or stent above the ampulla, preserving the function of the sphincter of Oddi, may lower the risk of future cholangitis by preventing enteric contamination of the biliary tree. Placement of a primary suprapapillary stent without a catheter, when possible, is the procedure most likely to keep the biliary tree sterile.

Benign biliary strictures are often due to a variety of etiologies, most of which are iatrogenic. Clinical presentation can vary from asymptomatic disease with elevated liver enzymes to obstructive jaundice and recurrent cholangitis. Diagnostic imaging methods, such as ultrasound, multidetector computed tomography, and magnetic resonance imaging (cholangiopancreatography), are used to identify stricture location, extent, and possible source of biliary obstruction. The management of benign biliary strictures requires a multidisciplinary team approach and include endoscopic, percutaneous, and surgical interventions. Percutaneous biliary interventions provide an alternative diagnostic and therapeutic approach, especially in patients who are not amenable to endoscopic evaluation. This review provides an overview of benign biliary strictures and percutaneous management by interventional radiologists. Diagnostic evaluation with percutaneous transhepatic cholangiography and treatment options, including biliary drainage, balloon dilation, retrievable/biodegradable stents, and other innovative minimally invasive options, are discussed.

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

Background: Malignant or benign biliary obstructions can be successfully managed with minimally invasive percutaneous interventions. Since percutaneous approaches are challenging, extensive training using relevant models is fundamental to improve the proficiency of percutaneous physicians. The aim of this experimental study was to develop an in vivo training model in pigs to simulate bile duct dilatation to be used during percutaneous biliary interventions. Materials and Methods: Twenty-eight large white pigs were involved and procedures were performed in an experimental hybrid operating room. Under general anesthesia, animals underwent a preoperative magnetic resonance cholangiography (MRC). Afterward, the common bile duct was isolated and ligated laparoscopically. A postoperative MRC was performed 72 hours after the procedure to evaluate bile duct dilatation. The In vivo models presenting an effective dilatation model were included in the hands-on part of a percutaneous surgery training course. Animals were euthanized at the end of the training session. Results: Postoperative MRC confirmed the presence of bile duct dilatation in the survival pigs (n = 25). No intraoperative complications occurred and mean operative time was 15.8 ± 5.27 minutes. During the course, 27 trainees could effectively perform percutaneous transhepatic cholangiography, bile duct drainage, biliary duct dilatation, and stent placement, with a > 90% success rate, thereby validating the experimental model. All animals survived during the training procedures and complications occurred in 28.3% of cases. Conclusion: The creation of an in vivo bile duct dilatation animal model is feasible with a low short-term mortality. It provides a realistic and meaningful training model in percutaneous biliary procedures.

Primary sclerosing cholangitis (PSC) is a cholestatic liver disease characterised by chronic inflammation and fibro-obliteration of the intrahepatic and/or extrahepatic bile ducts. It is associated with numerous hepatobiliary complications including an increased risk of malignancy (in particular, cholangiocarcinoma) and biliary tract stone formation. The evaluation of biliary strictures in patients with PSC is especially challenging, with imaging and endoscopic methods having only modest sensitivity for the diagnosis of cholangiocarcinoma, and treatment of biliary strictures poses a similarly significant clinical challenge. In recent years, peroral cholangioscopy has evolved technologically and increased in popularity as an endoscopic tool that can provide direct intraductal visualisation and facilitate therapeutic manipulation of the biliary tract. However, the indications for and effectiveness of its use in patients with PSC remain uncertain, with only a few studies performed on this small but important subset of patients. In this review, the authors discuss the available data regarding the use of peroral cholangioscopy in patients with PSC, with a focus on its use in the evaluation and management of biliary strictures and stones.

Interventional radiology (IR) is plays a crucial role in the management of localized infections, utilizing percutaneous access to loculated fluid collections for drainage and source control. Interventions have been developed in multiple organs and systems and used over decades, allowing the IR physician to provide patient care in many cases where surgical options are not optimal. In this review, we will examine the emergent, urgent, and routine nature of various IR procedures in the infectious context and timelines for each in regards to the decision making process. An algorithmic approach should guide the clinician's decision making for IR procedures in both large academic centers and smaller community hospitals. This approach and the pertinent procedural technique are described for multiple systems and organs including the biliary tree, gallbladder, genitourinary tract, and thoracic, abdominal, and pelvic abscesses. Increased awareness of the abilities and limitations of IR physicians in clinical scenarios needs to be implemented, to allow multispecialty input in efforts to decrease morbidity and mortality.

Percutaneous biliary interventions have established their role in the management of benign and malignant biliary disease. There are limited data comparing procedures performed by gastroenterologists and interventional radiologists in managing malignant biliary obstruction. Endoscopic procedures performed by gastroenterologists are not completely benign with reported complications ranging from 2% to 15%. It is important that gastroenterologists and interventional radiologists collaborate to form algorithms for management of malignant biliary obstruction which provide safe and efficacious care to these patients.

There is an increasing rivalry between percutaneous transhepatic (PTBD) vs. endoscopic ultrasound-guided biliary drainage (EUS-BD) as rescue techniques after failed endoscopic retrograde cholangiography (ERC) access. While EUS-BD procedures hold a bright future, innovations in PTBD technique are still possible and clinically meaningful, at least so, under the a conceptual framework understanding PTBD as a bridging, anatomy-respecting technology for definitive biliary metal stenting. This, however, calls for successful PTBD internalization as a sine qua non. Against this background, here, I present a novel approach of PTBD internalization using a standard triple-lumen papillotome as a stiff catheter for probing and assisting in guidewire cannulation of the route to the duodenum. This is the first report on such re-purposed use of a papillotome, which may be instrumental in fine-tuning contrast media filling and crossing angulations within the biliary system. Taken together, innovative advancements and variations in PTBD technique, such as the presented "antegrade papillotome navigation", may rescue difficult PTBD internalization and, thus, potentially obviate the need for alternative approaches, including pure EUS-BD or even more complex hybrid PTBD-EUS procedures.

Cholangioscopy allows direct visualization and subsequent therapeutic maneuvers of the biliary ductal system. With advances in endoscopic and imaging technology, cholangioscopy has become an important modality for the diagnosis of indeterminate biliary strictures and an essential therapeutic tool for difficult to remove biliary stones. Enhanced imaging and operability of the latest generation cholangioscopes have further expanded their clinical applications to include ductal tumor ablation, gallbladder drainage, access to difficult to reach branches of the biliary tree, and biliary foreign body manipulation. In this review, we discuss the technical evolution of cholangioscopy into the digital era and review the clinical evidence supporting its use in the diagnosis and therapy of biliary tract disease.