Patient selection and complications of transhepatic cholangiography

The most common diagnoses of transhepatic cholangiography (THC) among 58 surgical patients were pancreatic adenocarcinoma, choledocholithiasis and cholangiocarcinoma. THC was complicated in 17 of 58 patients or 18 of 68 attempts due to bacteremia or fever in four, subcapsular hematoma in two and Ring catheter shearing and apical pneumothorax in one each. THC related deaths occurred in four patients. In uncomplicated THC, the mean hematocrit value decreased from 35.9 +/- 5.8 (n = 39) to 34.1 +/- 4.8 (n = 39) (p less than 0.02). Of THC attempts, 8.8 per cent failed; before THC, ultrasonography (UTZ) in most of these showed no dilation of the bile ducts. THC showing dilated ducts had a significantly higher (p less than 0.01) bilirubin and alkaline phosphatase levels (14.8 +/- 8.7 milligrams per cent, n = 46 and 414 +/- 283.9 units, n = 46) compared with the THC showing no dilation (5.29 +/- 5.45 milligrams per cent, n = 13 and 235 +/- 294.1 units, n = 13). Of the 30 patients given ampicillin and gentamicin before THC, only three had bacteremia develop; two of six who were untreated and nine of 47 of those pretreated with other antibiotics had bacteremia develop. Of seven instances of stones of the common bile duct found at operation, computed tomography diagnosed zero of seven; UTZ, two of seven, and THC, seven of seven. No THC gave a misleading diagnosis. Eighteen palliative transhepatic drains were attempted with the THC (15 successfully). A significant (p less than 0.01) 50 per cent decrease in the bilirubin and alkaline phosphatase levels were obtained by catheter drainage but neither test returned to normal. THC is not a benign procedure and should be done only if bilirubin or alkaline phosphatase, or both, are elevated above 5 milligrams per cent and 200 units, respectively, and UTZ shows dilated biliary ducts. Pretreatment with antibiotics and operating room availability are important to limit THC morbidity.