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Biliary System

The need for biliary drainage in children is less frequent than in adults; however, there are a number of indications for performing a percutaneous transhepatic cholangiogram (PTC) (Diament et al. 1985). The most common indications for PTC is obstructive jaundice resulting from either a malignancy, most commonly rhabdomyosarcoma of the bile ducts or pancreas and neuroblastoma, or post liver transplantation. Cholithiasis is less frequently a causative agent (Lorenz et al. 2001; Roebuck and Stanley 2000; Rose et al. 2001). Cholangitis, which is a relatively common indication for PTC in adults, is rarely seen in children.

As in all percutaneous procedures, an uncorrectable coagulopathy is a definite contraindication for PTC. In children the procedure should be performed under general anaesthesia. Access to the biliary tree is gained by needle puncture; this can be done using fluoroscopy guidance, ultrasonography or a combination of both. We routinely use ultrasonography to access the biliary tree after which a small amount of contrast is injected to confirm appropriate placement of a 22-gauge needle. This stage of the procedure is usually performed using a Neff set (Cook, Bloomington, IN), thus reducing the risk of bile spill into the abdominal cavity. Using a guidewire the sheath is exchanged for a 6- or 8-F catheter. At this stage in the procedure one can either choose external biliary drainage or internal-external biliary drainage (Fig. 7.10) (RoEbuck and StANLEY 2000). In the latter a modified pigtail catheter is used: the modification consists of the presence of additional holes in the catheter along the intrahepatic tract of the catheter. The decision to perform external biliary drainage or internal-external biliary drainage is dependent on the findings of the cholangiogram. If passage into the duodenum is deemed possible, one should choose internal-external biliary drainage. If it is not possible in the first procedure it may be possible to convert external biliary drainage into internal-external biliary drainage at a later stage.

The advantage of internal-external biliary drainage over external biliary drainage is first of all that it re-establishes the flow of bile into the duodenum,

b

Fig. 7.10. a A 4-year-old boy with jaundice. The medical history of the boy revealed a neuroblastoma for which 131I-MIBG therapy was given. Magnetic resonance cholangiopancreatography (MRCP) coronal thin slice (TR 1837 ms, TE 249.2 ms, slice thickness 3 mm, flip angle 90°) shows clear dilatation of the intrahepatic bile ducts (arrows) and no visualization of the common bile duct. b Percutaneous transhepatic cholangiography in the same patient. Access route was via the left liver lobe, with dilatation of the left intrahepatic bile ducts (curved arrow). There is no passage of contrast to the right side of the gall tree or the duodenum. An 8.5-F pigtail drain (arrow) was placed and satisfactory extra biliary drainage was obtained. A second stage elective hepatico-jejunostomy was successfully performed several weeks later a thus enhancing the absorption of dietary fats. An additional advantage is that positioning of the catheter into the duodenum increases catheter stability, which of course is advantageous in smaller children.

PTC is not only used for catheter drainage but it also allows for dilatation of strictures of the biliary tree, which in children is mostly in cases of biliary-enteric anastomoses (Sze and Esquivel 2002). The advantage of balloon dilatation of strictures is the relatively minimal invasive approach and that, if dilatation fails, surgical options remain viable. Lorenz et al. (2005) reported their experience in 19 children over a 7-year period. In their study, 58% of patients showed a patent biliary-enteric anastomosis after 1 year (continued patency ranged from 1.4 to 5.4 years, mean patency 3.6 years).

Complications of PTC can be mild, such as hae-mobilia, pancreatitis, and bacteraemia, or severe, such as haemoperitoneum and sepsis (Lorenz et al. 2001). However, there is insufficient data to calculate the risk of the procedure in children.

If it is difficult to identify the bile duct, as can be the case in very young children, an alternative approach is to drain the biliary system via the gallbladder. This can of course only be done in cases of a distal obstruction (Fig. 7.11).

Another approach to the treatment of biliary obstructive jaundice is the use of endoscopic antegrade cholangiography (ERC). The main advantage of PTC over ERC is that it is a percutaneous technique that allows for easier access to the catheter in case of obstruction or infection. Secondly, PTC will be successful in cases of complete obstruction of the common bile duct because then external biliary drainage can be performed. Finally, ERC has a higher number of complications, such as pancreatitis and perforation, especially when the operator does not do the procedure on a regular basis. This is even more the case in children where special scopes are needed to perform a successful ERC. This procedure will therefore only be performed in specialized centres. The advantage of ERC over PTC lies mainly f?*Wr HEP ARTERY

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