Interventional procedures in hepatobiliary system

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Interventional procedures in hepatobiliary system

  1. 1. Interventional procedures in Hepatobiliary system
  2. 2. 1.Oncologic therapeutic procedures :  Tumor Embolization : Method that promotes tumor destruction by embolization of its suppliers vessels. ◦ Hepatic radioembolization  Tumor Ablations : Percutaneous local tumor destruction by using a device to cause cell death.
  3. 3. 2.Vascular Interventions  Trans-jugular intra hepatic portosystemic shunt (TIPS)  Transjugular liver biopsy (TJLB)
  4. 4. 3.Biliary interventions :  Percutaneous or endoscopic (ERCP)  Percutaneous transhepatic cholangiography (PTC)  Percutaneous transhepatic biliary drainage (PTBD)  Percutaneous cholecystostomy (PC)
  5. 5. 4.Others Percutaneous liver biopsy  Ultrasound guided  CT guided Percutaneous collections drainage  Ultrasound guided  CT guided
  6. 6. Liver CancerTreatments  Tumors need a blood supply, which they actively generate, to feed themselves and grow.  In treating cancer patients, interventional radiologists attack the cancer tumor from inside the body without medicating or affecting other parts of the body by using embolization and radiofrequency heat.
  7. 7.  Chemoembolization delivers a high dose of cancer-killing drug (chemotherapy) directly to the organ while depriving the tumor of its blood supply by blocking, or embolizing, the arteries feeding the tumor.
  8. 8.  In treating cancer patients, interventional radiologists use embolization to cut off the blood supply to the tumor (embolization), deliver radiation to a tumor (radioembolization), or combine this technique with chemotherapy to deliver the cancer drug directly to the tumor (chemoembolization).
  9. 9.  Chemoembolization is a minimally invasive treatment for liver cancer that can be used when there is too much tumor to treat with radiofrequency ablation (RFA), when the tumor is in a location that cannot be treated with RFA, or in combination with RFA or other treatments.
  10. 10.  Using imaging for guidance, a tiny catheter up the femoral artery in the groin into the blood vessels supplying the liver tumor.
  11. 11. Chemoembolization  The embolic agents keep the chemotherapy drug in the tumor by blocking the flow to other areas of the body.This allows for a higher dose of chemotherapy drug to be used, because less of the drug is able to circulate to the healthy cells in the body.
  12. 12.  Chemoembolization is a palliative, not a curative, treatment. It can be extremely effective in treating primary liver cancers, especially when combined with other therapies.
  13. 13. Catheter is placed via a transfemoral approach with tip within the selected hepatic artery
  14. 14. SIR-Sphere size is small enough to gain entry into tumor nodules but too large to pass through the end capillary bed into the venous circulation Tumor vessels 25μm -75μm End arterioles 8 μm SIR-Spheres mean diameter 35 μm
  15. 15. Yttrium-90 Radioembolization  Radioembolization is very similar to chemoembolization but with the use of radioactive microspheres.This therapy is used to treat both primary and metastatic liver tumors.
  16. 16.  This treatment incorporates the radioactive isotopeYttrium-90 into the embolic spheres to deliver radiation directly to the tumor. Each sphere is about the size of five red blood cells in width.
  17. 17.  These beads are injected through a catheter from the groin into the liver artery supplying the tumor.The beads become lodged within the tumor vessels where they exert their local radiation that causes cell death
  18. 18.  This technique allows for a higher, local dose of radiation to be used, without subjecting healthy tissue in the body to the radiation.
  19. 19.  Radioembolization is a palliative, not a curative, treatment-but patients benefit by extending their lives and improving their quality of life. It is a relatively new therapy that has been effective in treating primary and metastatic liver cancers. It is performed as an outpatient treatment.
  20. 20. TIPS  Portal hypertension condition in which the normal flow of blood through the liver is slowed or blocked by scarring (cirrhosis) or other damage (e.g. hepatitis). Patients with the condition are at risk of internal bleeding or other life-threatening complications. Transjugular intrahepatic portosystemic shunt (TIPS) formation is a minimally- invasive treatment to alleviate this impaired blood flow.
  21. 21. Indications 1. Prevention of variceal bleeding 2. Acute bleeding of esophageal varices that is refractory to medical therapies 3. Esophageal variceal rebleeding 4. Bleeding from gastric varices 5. Prevention of bleeding from portal hypertensive gastropathy 6. Ascites due to cirrhosis 7. Budd-Chiari syndrome 8. Veno-occlusive diseases
  22. 22. Absolute contraindications 1. Congestive heart failure 2. Multiple hepatic cysts 3. Uncontrolled systemic infection or sepsis 4. Unrelieved biliary obstruction 5. Severe pulmonary hypertension.
  23. 23. Relative contraindications 1. Hepatoma 2. Obstruction of all hepatic veins 3. Portal vein thrombosis 4. Thrombocytopenia of less than 20,000/cm(3) 5. Severe coagulopathy 6. Moderate pulmonary hypertension
  24. 24. TIPS • A catheter is placed in the right jugular vein • The catheter is threaded through the superior and inferior vena cava to the hepatic vein • Wall of the hepatic vein is punctured and the needle is directed across an approximate 2 inch gap to the portal vein • Successful passage into the portal vein is determined by the pattern of dye injected through the catheter
  25. 25. TIPS • A guide wire is threaded through the needle to maintain the passage between the hepatic and portal veins
  26. 26. TIPS • A balloon may be used across the passage to widen the holes in the vessel walls and the passage through the liver tissue
  27. 27. Biliary interventions :  Percutaneous or endoscopic (ERCP)  Percutaneous transhepatic cholangiography (PTC)  Percutaneous transhepatic biliary drainage (PTBD)  Percutaneous cholecystostomy (PC)
  28. 28.  There is a 5-15% incidence of retained stones after cholecystectomy  Associated with increased risk of recurrent biliary obstruction, pancreatitis, and cholangitis.  Benign/malignant strictures.
  29. 29. ERCP The diagnostic procedure of choice for abnormalities of the biliary and pancreatic ducts offers options of intervention:  Stone extraction  Sphincterotomy  Placement of stents
  30. 30.  A side viewing endoscope is advanced into the descending duodenum the papilla ofVater is identified and cannulated contrast is injected to visualize the pancreatic duct and biliary duct systems
  31. 31. Causes for ERCP failure include:  Upper GI stricture/stenosis  Complete ductal obstruction limiting retrograde filling  Postsurgical biliary-enteric fistula  Technical failure MRCP is an effective alternative when ERCP is unsuccessful
  32. 32. PercutaneousTranshepatic Cholangiography  Old reliable  Accurate technique for defining the site of obstruction  Provides option of tissue biopsy and/or intervention with drain or stent  Has been largely replaced by non-invasive techniques
  33. 33. Indications  Failed ERCP / ERCP not feasible (e.g. patients with gastrojejunostomy)  Biliary system delineation in presence of intra and extrahepatic biliary calculi  To identify obstructive cause of jaundice; and differentiate from medically treatable cause  Anatomic evaluation of complications of ERCP  Delineating bile leaks
  34. 34. Contraindications  Bleeding diathesis  Gross ascites
  35. 35. Technique ◦ Standard technique:Thin needle puncture in ninth or tenth intercostal space ◦ Contrast injected during slow withdrawal of the needle under fluoroscopic guidance ◦ When duct placement confirmed, additional injection ◦ Films taken in AP, right and left oblique
  36. 36. Surgical resection offers potential for cure but is rarely possible Palliation alternatives: 1. Surgical bypass 2. Percutaneous drainage 3. Endoscopic or percutaneous stent placement
  37. 37.  Three types of drains:External – does not cross obstruction, drains percutaneously  Internal-external – bile in obstructed segment enters through the side holes of the catheter and emerges beyond the obstruction; the external segment can be capped  Internal – drains only into enteric system
  38. 38. Percutaneous cholecystostomy  Image-guided placement of drainage catheter into gallbladder lumen.This minimally invasive procedure can aid stabilization of a patient to enable a more measured surgical approach with time for therapeutic planning.
  39. 39. Indications  poor surgical candidate/high risk patients with acute calculous or acalculous cholecystitis.  unexplained sepsis in critically ill patients (Diagnostic for cholecystitis as etiology of sepsis if clinical improvement after cholecystostomy).  access to or drainage of biliary tree following failed ERCP and PTC.
  40. 40. Contraindications Absolute contraindications  usually none Relative contraindications  bleeding diathesis: all attempts should be made to correct coagulopathy.  ascites  gallbladder tumor that might be seeded  gallbladder packed with calculi preventing catheter insertion
  41. 41. Thanks

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