Percutaneous transhepatic biliary drainage (PTBD) in staged treatment of complicated cholelithiasis — preventive vs «on demand»?

Objective. To analyze therapeutic and diagnostic capabilities of preventive preoperative percutaneous transhepatic biliary drainage (PTBD) in patients with complicated cholelithiasis and risk factors suggesting the indications for X-ray surgical intervention in postoperative period. Material and methods. There is a single-center, retrospective study. The most common causes of residual choledocholithiasis in the control group (n=32) were multiple choledocholangiolithiasis, megacholedocholithiasis, Mirizzi syndrome and combination of choledocholithiasis and biliary stricture. The same factors underlie prospective (main) group (n=18). In the control group, PTBD for antegrade X-ray surgical intervention aimed at eliminating ductal pathology was performed «ex tempore» after ineffective endoscopic and traditional surgical procedures. In the main group, PTBD was performed preventively, taking into account risk factors suggesting high probability of antegrade interventions in postoperative period. Results. In most cases, preventive PTBD in the main group was performed under comfortable dilation of biliary tree (77.8%), whereas forced drainage «on demand» was performed on non-dilated bile ducts in more than half of cases (53.1%). In both groups, PTBD was effective on dilated and non-dilated bile ducts, but the number of post-manipulation complications (Clavien—Dindo class I—III) was significantly higher in the control group (15 out of 32 (46.9%) patients vs. 2 out of 18 (11.1%) patients). Thus, potential safety of postoperative antegrade X-ray surgical intervention was significantly higher in patients with preoperative PTBD. Conclusion. A competent consideration of risk factors suggesting the need for postoperative X-ray surgical intervention allows us to determine the indications for preventive preoperative antegrade biliary drainage in patients with complicated cholelithiasis. Safety of X-ray surgical intervention largely depends on adequacy and conflict-free nature of percutaneous access. Preventive PTBD allows for dynamic fluoroscopic control at all stages of treatment. Preoperative access becomes safe in postoperative period due to formation of stable wound channel around drainage within a few days. This channel is absent in case of PTBD «ex tempore» in postoperative period.