Percutaneous Biliary Procedures

  • Kumble Seetharama Madhusudhan


Biliary interventions play a considerable role in the management of patients with various benign and malignant biliary diseases. Although, the endoscopic approach is the initial option in many, percutaneous biliary interventions have a substantial place in managing such patients. Commonly performed percutaneous biliary interventions include percutaneous transhepatic biliary drainage, biliary stenting, and percutaneous cholecystostomy. A radiologist, newly venturing into the field of interventional radiology, should be aware of and be trained in these commonly performed procedures. This chapter focusses on indications, basic steps, complications, and necessary advancements of various biliary procedures for the benefit of interventional radiologists.


Percutaneous transhepatic biliary drainage Biliary stenting Biliary radiofrequency ablation Percutaneous cholecystostomy Biliary stricture 


  1. 1.
    Perez-Johnston R, Deipolyi AR, Covey AM. Percutaneous biliary interventions. Gastroenterol Clin N Am. 2018;47:621–41.CrossRefGoogle Scholar
  2. 2.
    Madhusudhan KS, Gamanagatti S, Srivastava DN, Gupta AK. Radiological interventions in malignant biliary obstruction. World J Radiol. 2016;8(5):518–29.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Riaz A, Pinkard JP, Salem R, Lewandowski RJ. Percutaneous management of malignant biliary disease. J Surg Oncol. 2019;120:45–56.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Eklund JW, Trifilio S, Mulcahy MF. Chemotherapy dosing in the setting of liver dysfunction. Oncology (Williston Park). 2005;19(08):1057–63.Google Scholar
  5. 5.
    Ahmed O, Mathevosian S, Arslan B. Biliary interventions: tools and techniques of the trade, access, cholangiography, biopsy, cholangioscopy, cholangioplasty, stenting, stone extraction and brachytherapy. Semin Intervent Radiol. 2016;33:283–90.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Funaki B. Percutaneous biliary drainage. Semin Intervent Radiol. 2007;24(2):268–71.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS, Walker TG, et al. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol. 2012;23:727–36.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Venkatesan AM, Kundu S, Sacks D, Wallace MJ, Wojak JC, Rose SC, et al. Practice guidelines for adult antibiotic prophylaxis during vascular and interventional radiology procedures. Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular Interventional Radiological Society of Europe and Canadian Interventional Radiology Association. J Vasc Interv Radiol. 2010;21:1611–30.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Kumar Behera R, Narayan Srivastava D, Kumar P, et al. Right-sided versus left-sided percutaneous transhepatic biliary drainage in the management of malignant biliary obstruction: a randomized controlled study [published online ahead of print, 2020 Jul 22]. Abdom Radiol (NY). 2020.
  10. 10.
    Weber A, Gaa J, Rosca B, Born P, Neu B, Schmid RM, et al. Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts. Eur J Radiol. 2009;72:412–7.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Aung TH, Too CW, Kumar N, Damodharan K, Urlings TA, Patel A, et al. Severe bleeding after percutaneous transhepatic drainage of the biliary system. Radiology. 2016;278:957–8.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Quencer KB, Tadros AS, Marashi KB, Cizman Z, Reiner E, O’Hara R, et al. Bleeding after percutaneous transhepatic biliary drainage: incidence, causes and treatments. J Clin Med. 2018;7:94.PubMedCentralCrossRefGoogle Scholar
  13. 13.
    Madhusudhan KS, Dash NR, Afsan A, Gamanagatti S, Srivastava DN, Gupta AK. Delayed severe Hemobilia due to Bilio-venous fistula after percutaneous transhepatic biliary drainage: treatment with covered stent placement. J Clin Exp Hepatol. 2016;6(3):241–3.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Inal M, Aksungur E, Akgul E, Oguz M, Seydaoglu G. Percutaneous placement of metallic stents in malignant biliary obstruction: one-stage or two-stage procedure? Pre-dilate or not? Cardiovasc Intervent Radiol. 2003;26:40–5.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Chatzis N, Pfiffner R, Glenck M, Stolzmann P, Pfammatter T, Sharma P. Comparing percutaneous primary and secondary biliary stenting for malignant biliary obstruction: a retrospective clinical analysis. Indian J Radiol Imaging. 2013;23:38–45.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Gwon DI, Ko GY, Kim JH, Yoon HK, Lee IS, Kim KA, et al. A comparative analysis of PTFE-covered and uncovered stents for palliative treatment of malignant extrahepatic biliary obstruction. AJR Am J Roentgenol. 2010;195(6):W463–9.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Hyun H, Choi SY, Kim KA, Ko SB. Safety and efficacy of percutaneous biliary covered stent placement in patients with malignant biliary hilar obstruction; correlation with liver function. Cardiovasc Intervent Radiol. 2016;39(09):1298–305.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Shim DJ, Gwon DI, Han K, Kim Y, Ko GY, Shin JH, et al. Percutaneous metallic stent placement for palliative management of malignant biliary Hilar obstruction. Korean J Radiol. 2018;19(4):597–605.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Lee DH, Yu JS, Hwang JC, Kim KH. Percutaneous placement of self-expandable metallic biliary stents in malignant extrahepatic strictures: indications of transpapillary and suprapapillary methods. Korean J Radiol. 2000;1:65–72.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Jo JH, Park BH. Suprapapillary versus transpapillary stent placement for malignant biliary obstruction: which is better? J Vasc Interv Radiol. 2015;26(04):573–82.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Fu YF, Zhou WJ, Shi YB, Cao W, Cao C. Percutaneous stenting for malignant hilar biliary obstruction: a randomized controlled trial of unilateral versus bilateral stenting. Abdom Radiol (NY). 2019;44(8):2900–8.CrossRefGoogle Scholar
  22. 22.
    Karnabatidis D, Spiliopoulos S, Katsakiori P, Romanos O, Katsanos K, Siablis D. Percutaneous trans-hepatic bilateral biliary stenting in Bismuth IV malignant obstruction. World J Hepatol. 2013;5:114–9.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Xing GS, Geng JC, Han XW, Dai JH, Wu CY. Endobiliary brush cytology during percutaneous transhepatic cholangiodrainage in patients with obstructive jaundice. Hepatobiliary Pancreat Dis Int. 2005;4(1):98–103.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Boos J, Yoo RJ, Steinkeler J, Ayata G, Ahmed M, Sarwar A, et al. Fluoroscopic percutaneous brush cytology, forceps biopsy and both in tandem for diagnosis of malignant biliary obstruction. Eur Radiol. 2018;28(2):522–9.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Brugge WR, De Witt J, Klapman JB, Ashfaq R, Shidham V, Chhieng D, et al. Techniques for cytologic sampling of pancreatic and bile duct lesions: the Papanicolaou Society of Cytopathology Guidelines. Cytojournal. 2014;11(Suppl 1):2.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Mizandari M, Pai M, Xi F, Valek V, Tomas A, Quaretti P, et al. Percutaneous intraductal radiofrequency ablation is a safe treatment for malignant biliary obstruction: feasibility and early results. Cardiovasc Intervent Radiol. 2013;36(03):814–9.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Pai M, Valek V, Tomas A, Doros A, Quaretti P, Golfieri R, et al. Percutaneous intraductal radiofrequency ablation for clearance of occluded metal stent in malignant biliary obstruction: feasibility and early results. Cardiovasc Intervent Radiol. 2014;37(01):235–40.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Madhusudhan KS, Gamanagatti S, Gupta AK. Imaging and interventions in hilar cholangiocarcinoma: a review. World J Radiol. 2015;7(2):28–44.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Chen Y, Wang XL, Yan ZP, Cheng JM, Wang JH, Gong GQ, et al. HDR-192Ir intraluminal brachytherapy in treatment of malignant obstructive jaundice. World J Gastroenterol. 2004;10(23):3506–10.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Thompson CM, Saad NE, Quazi RR, Darcy MD, Picus DD, Menias CO. Management of iatrogenic bile duct injuries: role of the interventional radiologist. Radiographics. 2013;33:117–34.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Zajko AB, Sheng R, Zetti GM, Madariaga JR, Bron KM. Transhepatic balloon dilation of biliary strictures in liver transplant patients: a 10-year experience. J Vasc Interv Radiol. 1995;6:79–83.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Janssen JJ, van Delden OM, van Lienden KP, Rauws EA, Busch OR, van Gulik TM, et al. Percutaneous balloon dilatation and long-term drainage as treatment of anastomotic and nonanastomotic benign biliary strictures. Cardiovasc Intervent Radiol. 2014;37:1559–67.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    DePietro DM, Shlansky-Goldberg RD, Soulen MC, Stavropoulos SW, Mondschein JI, Dagli MS, et al. Long term outcomes of a benign biliary stricture protocol. J Vasc Interv Radiol. 2015;26:1032–9.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Cantwell CP, Pena CS, Gervais DA, Hahn PF, Dawson SL, Mueller PR. Thirty years’ experience with balloon dilation of benign postoperative biliary strictures: long-term outcomes. Radiology. 2008;249:1050–7.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Bonnel DH, Fingerhut AL. Percutaneous transhepatic balloon dilatation of benign bilioenteric strictures: long term results in 110 patients. Am J Surg. 2012;203:375–83.CrossRefGoogle Scholar
  36. 36.
    Saad WE, Davies MG, Saad NE, Waldman DL, Sahler LG, Lee DE, et al. Transhepatic dilation of anastomotic biliary strictures in liver transplant recipients with use of a combined cutting and conventional balloon protocol: technical safety and efficacy. J Vasc Interv Radiol. 2006;17:837–43.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Mukund A, Rajesh S, Agrawal N, Arora A, Arora A. Percutaneous management of resistant biliary-enteric anastomotic strictures with the use of a combined cutting and conventional balloon cholangioplasty protocol: a single-center experience. J Vasc Interv Radiol. 2015;26(4):560–5.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Bartel MJ, Higa JT, Tokar JL. The status of SEMS versus plastic stents for benign biliary strictures. Curr Gastroenterol Rep. 2019;21(7):29.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Yun G, Yoon CJ, Seong NJ. Percutaneous treatment of benign bilioenteric anastomotic strictures: temporary covered stent placement versus balloon dilatation. Eur Radiol. 2019;29(5):2690–7.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Mauri G, Michelozzi C, Melchiorre F, Poretti D, Pedicini V, Salvetti M, et al. Benign biliary strictures refractory to standard bilioplasty treated using polydoxanone biodegradable biliary stents: retrospective multicentric data analysis on 107 patients. Eur Radiol. 2016;26(11):4057–63.PubMedCrossRefGoogle Scholar
  41. 41.
    Stokes KR, Clouse ME. Biliary duct stones: percutaneous transhepatic removal. Cardiovasc Intervent Radiol. 1990;13:240–4.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Ryu JK. Percutaneous approach for removal of difficult common bile duct stones. Clin Endosc. 2013;46(1):3–4.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Ozcan N, Kahriman G, Mavili E. Percutaneous transhepatic removal of bile duct stones: results of 261 patients. Cardiovasc Intervent Radiol. 2012;35:621–7.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery. 2011;149:680–8.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Duconseil P, Turrini O, Ewald J, Berdah SV, Moutardier V, Delpero JR. Biliary complications after pancreaticoduodenectomy: skinny bile ducts are surgeons’ enemies. World J Surg. 2014;38:2946–51.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Weber A, Feussner H, Winkelmann F, Siewert JR, Schmid RM, Prinz C. Long-term outcome of endoscopic therapy in patients with bile duct injury after cholecystectomy. J Gastroenterol Hepatol. 2009;24(5):762–9.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    May K, Hunold P. Leakage of hepaticojejunal anastomosis: radiological interventional therapy. Visc Med. 2017;33:192–6.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Saad N, Darcy MD. Iatrogenic bile duct injury during laparoscopic cholecystectomy. Tech Vasc Interv Radiol. 2008;11(2):102–10.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Angileri SA, Gorga G, Tortora S, Avrilingi M, Petrillo M, Ierardi AM, et al. Biliary injuries after pancreatic surgery: interventional radiology management. Gland Surg. 2019;8:141–9.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Stampfl U, Hackert T, Radeleff B, Sommer CM, Stampfl S, Werner J, et al. Percutaneous management of postoperative Bile leaks after upper gastrointestinal surgery. Cardiovasc Intervent Radiol. 2011;34:808–15.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Akhan O, Akinci D, Ozmen MN. Percutaneous cholecystostomy. Eur Radiol. 2002;43:229–36.CrossRefGoogle Scholar
  52. 52.
    Little MW, Briggs JH, Tapping CR, Bratby MJ, Anthony S, Phillips-Hughes J, et al. Percutaneous cholecystostomy: the radiologist’s role in treating acute cholecystitis. Clin Radiol. 2013;68:654–60.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Venara A, Carretier V, Lebigot J, Lermite E. Technique and indications of percutaneous cholecystostomy in the management of cholecystitis in 2014. J Visc Surg. 2014;151:435–9.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Beland MD, Patel L, Ahn SH, Grand DJ. Image-guided cholecystostomy tube placement: short and long term outcomes of transhepatic versus transperitoneal placement. Am J Roentgenol. 2019;212:201–4.CrossRefGoogle Scholar
  55. 55.
    Loberant N, Notes Y, Eitan A, Yakir O, Bickel A. Comparison of early outcome from transperitoneal versus transhepatic percutaneous cholecystostomy. Hepato-Gastroenterology. 2010;57:12–7.PubMedPubMedCentralGoogle Scholar
  56. 56.
    VanSonnenberg E, D’Agostino HB, Goodacre BW, Sanchez RB, Casola G. Percutaneous gallbladder puncture and cholecystostomy: results, complications, and caveats for safety. Radiology. 1992;183:167–70.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Hatzidakis A, Venetucci P, Krokidis M, Iaccarino V. Percutaneous biliary interventions through the gallbladder and the cystic duct: what the radiologists need to know. Clin Radiol. 2014;69:1304–11.PubMedCrossRefPubMedCentralGoogle Scholar
  58. 58.
    Ginat D, Saad WE. Cholecystostomy and transcholecystic biliary access. Tech Vasc Interv Radiol. 2008;11:2–13.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2021

Authors and Affiliations

  • Kumble Seetharama Madhusudhan
    • 1
  1. 1.Department of RadiodiagnosisAll India Institute of Medical SciencesNew DelhiIndia

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