Indications

• Biliary obstruction (malignancy, anastomotic stricture, or stone)

• Biliary leak for diversion

• ERCP not possible (sometimes post-Whipple)

Contraindications

• Multi-segmental obstruction (if peripheral branches are too small to cannulate)

• Uncorrectable coagulopathy

• Contrast allergy

Imaging Review

• Typically US, CT, and/or MRCP already performed

• Assess level of obstruction, degree of duct dilation, variant anatomy

• Will it be possible to pass an internal/external biliary drain down the CBD into the duodenum? Or are we just leaving an externally-draining catheter?

• Note that an atrophic parenchymal lobe may not benefit from drainage

• Identify tumors or cysts that may limit the approach

Tips for Workup

• Pertinent hx: Suspected etiology of obstruction or leak? Recent surgery?

• Procedure is one of the most painful in IR, despite moderate sedation. Consider involving anesthesia if time allows.

• Consent:

  • • Peri-procedural complications: Hemobilia (pseudoaneurysm, arterial or venous fistula with biliary tree), subcapsular hematoma, pneumothorax, sepsis

    • Delayed complications: hemobilia, bile peritonitis, stent occlusion, pleural effusion/empyema, electrolyte depletion from bile output