Please correct the codes..
1. Peicutaneous transhepatic cholangiogram.
2. Internal biliary stent placement with biliary ductal dilatation.
3. External biliary drainage catheter placement.
INDICAION: Patient with malignant biliary obstruction. PROCEDE E: All possible risks, complications and alternatives were discussed with the patient, including bleeding, infection, need for surger and death. Additionally, the procedure was discussed with the referring physician, Dr. Cabral and Dr. Sable.
The patientâ€™s abdomen was cleaned and prepped in the usual sterile fashioi . The Department of Anesthesia was present. General anesthesia was usd for this procedure. From a right mid-axillary approach, a 22-gauce needle was advanced. The needle was seen entering a right-sided bile dict. Contrast injections and transhepatic cholangiogram were perforied. Multiple attempts were made to access the right-sided duct. Secondary to the patientâ€™s respiratory rate of 30 to 35 with rapid irregular breathing, it was decided to ask Anesthesia to intubate and deepen the sedation. Once this was accomplished, again the needle was advanced into the central duct. Contrast opacification was again perforred. From a midline/subcostal approach the left biliary ducts were accessed. The needle tip was clearly seen entering the bile duct. A 0.018 inch wire was then advanced. The needle was removed over the wire and a #11 blade was used to make a small dermatotomy. The AccuStick sheath was then advanced over the wire. The stylette was held still as the sheath was advanced. The wire was navigated into the common bile duct aid then the catheter was advanced. The wire was removed. Then a 4-French Cobra catheter and a 0.035 angled glidewire was used to cross the occlusion of the distal bile duct. Once this was accomplished the catheter was advanced. The wire was removed and contrast injection was perforred which opacified the small bowel. Then the catheter was advanced over the wire. A super-stiff Amplatz wire was advanced. The catheter was removed and then the4-French AccuStick sheath was removed. Then oer the wire a 7-French long vascular access sheath was advanced. Contrast injections were performed to evaluate the distal bile duct. Road mapping was performed. An 8 x 60 mm Smart stent was then advanced over tie wire. Under direct fluoroscopic observation the stent was deployed. Spot images were obtained. There was a tight stenosis in the stent. An 8 x 4 standard angioplasty balloon was used to post dilate the stent nd was brought to profile. Contrast injections demonstrated good flow of bile through the stent into the small bowel. Then the stent device was removed over the wire. The 7-French vascular access sheath was reroved over the wire. An 8-French all purpose drainage catheter was advanced with the pigtail formed above the level of the biliary stent. The tute will be left open for two hours and then capped.
OBSERV4TIONS: As described, there is diffuse mild intrahepatic biliary ductal dilatation and moderate extrahepatic ductal dilatation.
Cholanc iogram was performed and demonstrated a severe stricture/stenosis in the listal common bile duct. This lesion was crossed from a
left-sided approach as described. After stent placement and balloon
dilatation, there was successful opening of the stricture/occlusion. The pigtail catheter is seen in good position.
IMPRESSION: Technically successful percutaneous transhepatic
cholangiogram with biliary dilatation and internal and separate external stent placement, as described. No immediate post procedural
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