Transjugular Percutaneous Cholangiography

Abstract

A method of performing percutaneous cholangiography is suggested that may substantially reduce the incidence of bile peritonitis and also alleviate the necessity of immediate operation when an obstructive biliary lesion is encountered. By passing a catheter percutaneously via the right internal jugular vein, a direct line approach is made available to the hepatic vein via the superior vena cava, right atrium, and the inferior vena cava. Through this catheter a needle may be inserted for percutaneous cholangiography by puncturing the bile ducts from inside the liver. Technic Under sterile conditions, an area of skin and subcutaneous tissue is anesthetized with local anesthesia about 3 cm below the angle of the mandible and immediately medial to the sternocleidomastoid muscle. A 3 mm stab wound of the skin and subcutaneous tissues is made to prevent later hang-up of the catheter. An 18-gauge thin-walled needle approximately 8 cm long is attached to a 10 cc plain tip syringe containing 7 cc of 1 per cent X ylocaine (Fig. 1). The needle tip is directed caudad and approximately 1 cm lateral to the common carotid artery. While the needle is being advanced, small amounts ofXylocaine are injected intermittently whenever the patient experiences pain. The needle is inserted for approximately 7 cm and is aspirated during the slow withdrawal. A brisk return of dark blood will indicate the internal jugular vein has been entered. A Seldinger-type guide wire, with an outside diameter of 0.031 in. and approximately 150 cm long, is inserted through the needle and the needle withdrawn over it. A Teflon catheter, which is part of the Ross needle system of transseptal heart catheterization equipment, can then be inserted by the Seldinger technic. On occasion, this catheter may become hung up on fascial planes in the neck. We maintain a separate thick-walled, longtapered Teflon catheter specifically for dilating a channel from the skin to the internal jugular vein, should the need arise. The catheter and guide wire are advanced down the superior vena cava, across the right atrium, into the inferior vena cava, and then directed into an hepatic vein. The guide wire is removed, and the position of the catheter tip is then verified by use of an image intensifier and the injection of 5 to 10 cc of 60 per cent meglumine iothalamate. An image intensifier capable of fluoroscopy in both the anteroposterior and lateral planes greatly facilitates accurate placement of the catheter. Through the catheter, an 18-gauge modified Ross needle is inserted and advanced until its tip lies well in the selected hepatic vein. The catheter is partially withdrawn from the jugular vein so that the tip of the modified Ross needle protrudes approximately 5 to 6 mm distal to the catheter. The needle tip is withdrawn slightly, and a gentle attempt is made to direct it toward the hilus of the liver. With a sudden thrust of 1 to 2 cm, the needle tip is inserted into the liver parenchyma.