Application Of Digital Subtraction Cholangiography Combined With Ultrasound Guidance In Percutaneous Difficult Bile Duct Catheterization

Research background and purpose:Research background:As a minimally invasive treatment,percutaneous puncture technique is widely used in the treatment and diagnosis of biliary obstruction diseases.To solve the problems related to biliary obstruction,an artificial channel between the intrahepatic biliary tract and the external biliary tract was established by puncture of the intrahepatic bile duct.For complete biliary obstruction,the persistence of obstruction will lead to cholestasis,which will cause a series of changes in indicators,including abnormal liver function,abnormal renal function,abnormal coagulation function,water and electrolyte disorders,which seriously affect the quality of life of patients and is the primary cause of death of patients.In the case of incomplete biliary obstruction,long-term non-smooth bile discharge can lead to cholangitis and sepsis.All patients with symptomatic obstructive biliary diseases should be treated actively.As a minimally invasive treatment,percutaneous transhepatic biliary drainage can be used as a palliative treatment for biliary drainage.For malignant biliary obstruction,surgery is the only way to cure,but for patients who lose the opportunity for surgery or have preoperative indications for biliary drainage,percutaneous transhepatic cholangial drainage is an important method to prolong the survival time of patients and correct liver function and coagulation function before operation.It can also be used as a way to establish artificial channels for the next treatment.Research purpose:In clinical practice,it is difficult to perform percutaneous transhepatic biliary drainage in patients with bile duct diameter ≤4mm and patients with a history of multiple catheterization,which was once considered to be the category of difficult bile duct catheterization.In this study,patients with target bile duct diameter ≤4mm and patients with a history of multiple catheterization were defined as difficult catheterization.To compare the clinical efficacy,prognosis and safety of digital subtraction cholangiography(DSA)combined with ultrasound guidance and ultrasound guidance alone in percutaneous transhepatic biliary drainage(PTCD)in patients with difficult bile ducts,and to provide a basis for clinical selection of drainage guidance under different circumstances.Methods:The clinical datas of 60 patients with biliary obstructive diseases who were admitted to the First People’s Hospital of Neijiang City from January 2020 to June 2022 and required percutaneous transhepatic biliary drainage related treatment were retrospectively collected.According to the different guidance methods of percutaneous transhepatic biliary drainage,the patients were divided into digital subtraction cholangiography combined with ultrasound group and ultrasound alone group.A total of20 patients were included in the digital subtraction cholangiography combined with ultrasound group,and 40 patients were included in the ultrasound alone group.The preoperative,intraoperative,postoperative and follow-up data were compared between the digital subtraction cholangiography combined with ultrasound group and the ultrasound group,and the subgroup analysis was performed according to the maximum diameter of the target puncture bile duct and the history of catheterization.Observation indicators included age,gender,maximum diameter of target bile duct,disease type,liver function indexes(total bilirubin,direct bilirubin,alanine aminotransferase,aspartate aminotransferase),operation time,puncture times,operation success rate,intraoperative mispuncture rate,changes in liver function indexes before and after operation,and the incidence of tube detachment or disability in 3 months.Results:1.Comparison of general informationThere was no significant difference in gender,age,maximum diameter of target bile duct,disease,liver function(total bilirubin,direct bilirubin,alanine aminotransferase,aspartate aminotransferase)and other indicators between the two groups before operation.2.Comparison of clinical efficacy1)Comparison of operation timeIn terms of operation time,the digital subtraction cholangiography combined with ultrasound group was significantly lower than that of the ultrasound group,and the difference was statistically significant(P < 0.05).Subgroup analysis was performed according to the diameter of the bile duct.The operation time of the digital subtraction cholangiography group in the ≤4mm and > 4mm group was less than that of the simple ultrasound guidance group,and the difference was statistically significant(P < 0.05).2)comparison of puncture timesIn terms of the number of punctures,the average number of punctures in the digital subtraction cholangiography combined with ultrasound group was less than that in the ultrasound group,but the difference was not statistically significant(P < 0.05).According to the diameter of bile duct,the number of puncture in the digital subtraction cholangiography group was less than that in the ultrasound guided group in the ≤4mm and > 4mm groups,and the difference was statistically significant(P < 0.05).3)the success rate of surgeryIn terms of the success rate of operation,the success rate of operation in digital subtraction cholangiography combined with ultrasound group was 95%,and the success rate of operation in ultrasound group was 50%,the difference was statistically significant(P < 0.05).According to the diameter of the bile duct,the success rate of digital subtraction cholangiography combined with ultrasound group in ≤4mm and >4mm group was 91.7% and 100%,respectively.There was a significant difference in the diameter of bile duct ≤4mm between the digital subtraction cholangiography combined with ultrasound group and the ultrasound group(P < 0.05).In the > 4mm group,there was no failure in the digital subtraction cholangiography combined with ultrasound group.According to the different times of catheterization,the success rate of digital subtraction cholangiography combined with ultrasound guidance for the first time was93.3%,and the success rate of ultrasound guidance alone was 56.3%,the difference was statistically significant(P < 0.05).The success rate of digital subtraction cholangiography combined with ultrasound guidance in the multiple group was 100%,and there was no failure case,and the success rate of ultrasound guidance alone was25%.4)comparison of drainage efficacyIn the comparison of efficacy indicators before and after drainage,the changes of total bilirubin,direct bilirubin and aspartate aminotransferase before and after treatment were statistically significant(P < 0.05),while the changes of alanine aminotransferase before and after treatment were not statistically significant(P > 0.05).5)the rate of extubation and/or disability at 3 months after operationThere was no significant difference in the incidence of extubation and/or disability between the two groups within 3 months after operation(P > 0.05).2.Safety comparison1)The rate of accidental vessel punctureThere was 1 case of mispuncture of blood vessel in the digital subtraction cholangiography combined with ultrasound group,and the mispuncture rate was 5%.There were 4 cases of mispuncture in the ultrasound group,and the mispuncture rate was 10%.There was no significant difference between the two groups(P > 0.05).Conclusions:Digital subtraction cholangiography combined with ultrasound guidance can be used in patients undergoing percutaneous transhepatic biliary drainage.For patient s with the maximum diameter of bile duct ≤4mm,the safety and clinical effica cy are better than those of ultrasound alone.Digital subtraction cholangiography combined with ultrasound-guided operation can be used as an alternative guidanc e method,but digital subtraction cholangiography technology is an interventional technology,and there is radiation to the patient during the operation.Preoperativecommunication and radiation protection should be done before the operation.Di gital subtraction cholangiography combined with ultrasound is recommended for p atients with the maximum diameter of the target bile duct ≤4mm and a history of multiple catheterization.