Liver Interventions

We welcome 

Our first batch of DNB Radiology students in Meenakshi hospital, Tanjore

Minimally Invasive Image-Guided Therapies

1. Liver Abscess Drainage (Percutaneous)

Technique

• Patient in supine position. US/CT guidance.
• Local anesthesia.
• Needle puncture into abscess under real-time imaging.
• Guidewire insertion.
• Tract dilatation.
• Drainage catheter placement (pigtail or multipurpose).
• Aspiration of pus and catheter connected to drainage bag.
• Catheter flushed regularly and removed when output minimal and cavity collapsed.

Indications

• Pyogenic liver abscess (solitary or multiple)
• Amoebic liver abscess (large or non-responding to medical therapy)
• Abscess not accessible endoscopically
• Sepsis not responding to antibiotics

Contraindications

• Uncorrected coagulopathy
• Lack of safe percutaneous access
• Multiple small abscesses (<3 cm) responding to antibiotics

IMAGING

USG: Abscess

CT: Catheter in abscess

Advantages of Liver Abscess Drainage

• High success rate (85-95%)
• Minimally invasive, safe and effective
• Short hospital stay, cost effective
• Can be done under local anesthesia
• Can be repeated if needed

2. Percutaneous Cholecystostomy (Pc)

Technique

• Patient supine, right side up.
• USG guidance.
• Local anesthesia.
• Transhepatic or transperitoneal puncture of gallbladder.
• Guidewire insertion.
• Tract dilatation.
• 7 Drainage catheter placement (8-12 Fr pigtail).
• Bile aspiration and catheter connected to drainage bag.
• Catheter removed after clinical improvement (usually 3-6 weeks).

Indications

• Acute cholecystitis in high-risk surgical patients
• Critically ill/unfit for surgery
• Sepsis due to gallbladder infection
• Bridge to surgery

Contraindications

• Uncorrected coagulopathy
• No safe percutaneous window (intervening bowel)
• Gallbladder perforation with generalized peritonitis

IMAGING

USG: Distended GB

PC catheter in GB

Advantages of PC

• Effective decompression and sepsis control
• Alternative to emergency surgery
• Can be performed under local anesthesia
• Minimally invasive with low morbidity
• Can be used as bridge to definitive surger

3. Percutaneous Transhepatic Biliary Drainage (Ptbd)

Technique

• Patient supine.
• USG guidance - puncture of dilated intrahepatic bile duct.
• Cholangiography.
• Guidewire negotiation across obstruction (if possible).
• Tract dilatation.
• External drainage catheter placement (8-12 Fr pigtail).
• Bile drainage and monitoring.
• Internal-external drainage or stenting in selected cases.

Indications

• Malignant distal biliary obstruction
• Benign biliary strictures
• Failed/endoscopic drainage not possible
• Preoperative biliary drainage

Contraindications

• Uncorrected coagulopathy
• No dilated intrahepatic bile ducts
• Severe ascites (relative)
• Intrahepatic vascular anomalies (relative)

IMAGING

PTC showing biliary obstruction

PTBD catheter in situ

Advantages of PTBD

• Relieves obstructive jaundice
• Improves liver function
• Allows definitive treatment later
• Can be done when ERCP not possible
• Option for long-term drainage or stenting

4. Biliary Stenting

Technique

• Access via PTBD route or endoscopic route (ERCP).
• Guidewire across stricture.
• Cholangiography.
• Balloon dilatation (if needed).
• Stent deployment across stricture (plastic or self-expanding metal stent - SEMS).
• Check position and bile flow.
• External drain removed if internal drainage adequate.

Indications

• Malignant biliary obstruction
• Benign biliary strictures
• Inoperable pancreatic/biliary malignancies
• Post-surgical biliary strictures

Contraindications

• Uncorrected coagulopathy
• Active cholangitis (relative -treat and then stent)
• Lack of access to biliary system

Imaging​

PTC showing biliary obstruction

PTBD catheter in situ

Advantages of Biliary Stenting

• Effective and durable relief of obstruction
• SEMS has longer patency
• Improves quality of life and survival
• Minimally invasive
• Can be repeated or revised if needed

General Advantages of Image-guided Liver Interventions

Minimally Invasive Small puncture, less pain, faster secovery

High Success Rate Excellent clinical outcomes

Safe & Effective Performed under Image guidance (USG/CT/Fluoroscopy)

Short Hospital Stay Early mobilization and discharge

Cost Effective Lower cost compared to surgery

Repeatable Can be repeated when necessary

Improves Quality of Life Relieves symptoms and improves survival

Important Advice

• Always correct coagulopathy ( INR 50,000), give appropriate antibiotics and ensure informed consent.