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Common Interventional Procedures

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

Endoscopic Retrograde CholangioPancreatography or ERCP is, as the name implies, an endoscopic test in which the common opening of the bile and pancreatic duct in the duodenum is cannulated to overcome ductal obstructions by removing stones, widening strictures or inserting stents. Sometimes this procedure is used to provide pictures of the shape and size of the bile duct or pancreatic duct for diagnostic purposes although MRCP has largely taken over this role. ERCP is also moderately effective at taking biopsies from tumours in the bile and pancreatic ducts.

As for any endoscopic procedure, it is necessary to be fasting for at least 6 hours prior to ERCP. As some of the procedures may cause minor bleeding, your doctor will have checked blood tests to ensure that your blood clots normally. The procedure itself takes about 15 minutes and is performed under sedation, but not unusually under complete general anaesthesia. Antibiotics are given to prevent or treat infection.

You will usually be able to start on fluids upon regaining consciousness after the procedure. Sometimes when certain special procedures have been performed your doctor will advise you to remain fasting for longer. Most patients will be able to return home on the same day as the procedure but some need to stay overnight. This is a safe procedure with virtually no risk to life. The complications specific to this procedure, occur in 2-10% of patients and include bleeding, transient inflammation of the pancreas and very rarely bowel perforation. In a small minority of patients cannulation of the bile and pancreatic ducts is unsuccessful, resulting in the procedure being abandoned.

ENDOSCOPIC ULTRASOUND (EUS)

Endoscopic Ultrasound or EUS is an endoscopic procedure in which a small high-frequency ultrasound scanner is placed at the tip of the endoscope. The scanner can then be positioned inside the bowel very close to the region of interest. EUS provides very detailed pictures of the pancreas, bile duct and left lobe of the liver from within the stomach. It permits accurate biopsies of diseased areas. It may be used to perform coeliac axis nerve blocks and to aid in cannulation of the bile duct when standard ERCP has been unsuccessful.

This procedure requires 6-8 hours of fasting and is performed under sedation. Patients may begin drinking fluids as soon as they regain consciousness. They can be discharged on the same day as the procedure.

PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE (PTBD)

Percutaneous Transhepatic Biliary Drainage is a procedure that drains bile externally through a drainage tube inserted through the skin into the liver. It is used to drain bile when the bile duct is blocked and unable to drain into the intestine as it normally should. Bile that remains stagnant within the liver may become infected, and drainage helps to treat infection. The same route may be used to negotiate the drainage tube across the bile duct blockage and permit drainage into the bowel. This technique is particularly useful in high bile ducts obstruction.

The procedure is performed under local anaesthesia with sedation or sometimes under general anaesthesia in the radiology suite under x-ray control. Blood tests to ensure satisfactory clotting are essential prior to the procedure. These parameters must be corrected prior to the procedure.

LIVER BIOPSY

Liver biopsy involves inserting a needle into the liver to extract a small piece for evaluation. The needle is inserted into the liver under local anaesthesia usually from between the lower right ribs. The biopsy is performed under ultrasound or CT control so that the Radiologist can place the tip of the needle accurately. The procedure itself takes just a few seconds to perform. During the procedure you will be asked to hold your breath so that the liver does not move while the needle is within it.

This procedure is associated with a 1% risk of bleeding. Your doctor will check that your blood is clotting normally prior to performing this procedure and will correct any abnormality before proceeding with liver biopsy. You will be advised to lie on your right side in order to minimize movement of the liver after the procedure and will usually be observed overnight to ensure there has been no bleeding.

TRANSARTERIAL CHEMOEMBOLIZATION (TACE)
Transarterial Chemoembolization (TACE) is a minimally invasive procedure used in the treatment of liver tumors. This is primarily useful for primary liver tumors such as hepatocellular carcinoma though it may also be considered in other tumors on a case-by-case basis.

TACE is based on the principle that while normal healthy liver receives blood through the portal vein, the liver tumor receives it primarily from another source, the hepatic artery. By specifically targeting the hepatic artery and giving chemotherapy medications into this artery and the blocking it, the tumor cells are selectively damaged by the chemotherapy and starved of nutrients and oxygen leading to necrosis of the tumor. With improved techniques, highly selective TACE, where only the branch of the hepatic artery supplying the particular tumor can be treated, thus decreasing the adverse effects. The advantage of TACE is that it can be repeated at regular intervals (usually 2-3 months) while monitoring the treatment response with regular CT scan.

TACE unfortunately is not a curative treatment. It can only control the disease and thus prolong life. It has two particular roles in the management of hepatocellular carcinoma. It can be used as a bridging therapy to decrease the risk of tumor progressing while a patient is waiting for liver transplantation as a definitive cure for the liver disease and tumor. Its other role is as a palliative treatment in advanced tumors where transplantation is not option advisable. It has been used as a test to assess the biology of the tumor. Tumors, which respond well to TACE, have a better biology and have an excellent outcome after transplantation. On the other hand tumors which do not respond to TACE and continue to progress despite treatment are associated with poor biology and the chance of post-transplant tumor recurrence is higher in these cases.

The procedural complications of TACE itself are minimal in expert hands. Complications after the procedure are primarily related to the background liver cirrhosis. Patients should be carefully selected for TACE as presence of very advanced liver disease increases the risk of post-TACE complications. In such patients, the liver function can get worse after the procedure leading to increased jaundice, fluid in abdomen or even encephalopathy. This usually improves with careful supportive treatment.

TRANSARTERIAL RADIO EMBOLIZATION (TARE)
Trans-arterial radio embolisation also known as radioembolization or SIRT is another way of treatment of advanced hepatocellular carcinoma. Here special radioactive particles are deposit into the hepatic artery branches supplying the tumor. The intense radioactivity causes damage and death of the tumor with minimal damage to the surrounding liver. This technique is especially useful when there is blockage of the portal vein (the main blood vessel which supplies the majority of blood to the liver) where non-selective TACE can cause more side-effects.

The patient should be carefully tested to assess his/her suitability for TARE. These tests will include testing the liver function and also check for presence of abnormal connections between the blood supply of the liver and lungs. The main issue with TARE is that is it much more expensive when compared to TACE because of the cost of the radioactive beads used in the procedure. Hence it is used very selectively and we are one of the very few centres in India who offer this treatment.

Side-effects during the procedure are minimal. However, similar to TACE, the risk of temporary deterioration in liver function after treatment is possible. Hence close followup after the procedure is necessary.

RADIO FREQUENCY ABLATION (RFA)
Radiofrequency ablation is a procedure where the liver tumor is burnt using high energy passing through a probe that is inserted into the tumor. Depending on the location of the tumor and other factors, the probe can be inserted through the skin under local anesthesia or at surgery. The procedure takes about 30-45 minutes and is highly effective for small tumors (less than 3cms). Close followup with periodic CT scans is necessary to identify any new tumors or regrowth of the old tumor in these patients.

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)
Transjugular Intrahepatic Portosystemic shunt is an interventional procedure for patients with complications due to liver disease such as ascites, kidney failure of gut bleeding. Here an artificial channel is made through the liver to decompress the high-pressure portal vein draining blood from the gut. The patient should be carefully assessed prior to this procedure and only a selected few will be suitable as encephalopathy after the procedure can be a major problem in some patients.