Percutaneous Transhepatic Cholangiography

Percutaneous transhepatic cholangiography is a highly useful and valuable technic providing important anatomic information that can be obtained in no other way. It is particularly helpful in the presence of clinical or chemical jaundice, where conventional diagnostic x-ray examination of the gallbladder and bile ducts offers no help. It permits the differentiation between obstructive and hepatocellular jaundice and offers the opportunity of diagnosis prior to surgical exploration. It is furthermore capable of demonstrating intrahepatic disease not identifiable by other known preoperative or operative diagnostic methods. It furnishes far more information regarding the intrahepatic bile ducts than is obtainable by operative cholangiography. We have been impressed by the ability of this technic to provide definitive diagnostic information in situations which might otherwise require exploratory laparotomy. Obstructive lesions of the biliary system are difficult problems for the surgeon. Patients are frequently in the older age group and are generally poor surgical risks. Any advance information regarding the morphologic character of the disease present may well be decisive in determining the type of surgical or medical therapy indicated. We feel that when the indications are proper and the examination is done in the immediate preoperative period, percutaneous transhepatic cholangiography has distinct value. It is entirely possible that, with additional clinical experience and in carefully supervised cases, it need not necessarily be followed by immediate surgery provided the patient remains in the hospital under careful observation and competent surgical assistance is readily available if required. Indeed, the results of the examination may well obviate the need for surgery. Historical Review The earliest attempt at opacifying the biliary tree percutaneously dates back to 1921, when Burkhardt and Müller (2) reported percutaneous injection of the gallbladder with opaque material in 3 patients. In 1937, Huard and Do-Xuan-Hop (6) introduced Lipiodol percutaneously into the liver and demonstrated the intrahepatic biliary tree. Royer and Solari in 1942 (12) injected a radiopaque medium into the gallbladder under direct visualization at peritoneoscopy. This method is, of course, limited to patients in whom the gallbladder can be located with the peritoneoscope. In a later report Royer et al. (13) described another method for the percutaneous injection of the biliary tree. They inserted an opaque catheter in the duodenum as a marker and located the superior duodenal angle on the abdominal wall as a point of reference. With this method, if visualization of the hepatic duct is desired, the percutaneous injection is made 3 to 4 cm. cephalad and 1 to 2 cm. lateral to the reference point. If, on the other hand, visualization of the gallbladder is the object, the injection is made 3 to 4 cm. lateral and 1 to 2 cm. inferior to the reference point.