Quality Improvement Guidelines for SIR Procedures

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Questions and Answers

What is the procedural success threshold for aspiration of gallbladder contents using a 21-gauge needle?

90%

50%

80% (correct)

95%

A minimum threshold for success rates indicates that a review should be performed when the rates fall below it.

True

What is the clinical success rate for a single aspiration of gallbladder contents?

50%

The technical success rate for cholecystostomy drain placement is ________.

90% Signup and view all the answers

Match the following outcomes with their corresponding success rates:

21-gauge needle aspiration = 80% Cholecystostomy drain placement = 90% Single aspiration clinical success = 50% Multiple aspirations clinical success = 80% Signup and view all the answers

What is one measure used to evaluate the quality of percutaneous transhepatic cholangiography?

Incidence of sepsis Signup and view all the answers

Universal thresholds are easy to set for determining the quality of cholecystostomy procedures.

False Signup and view all the answers

What factors should be monitored post-procedure to ensure successful patient outcomes?

Pain, fever, white blood cell count, and C-reactive protein Signup and view all the answers

____ in excess of the defined threshold should trigger policy reviews to improve quality.

Values Signup and view all the answers

Which complication is specifically associated with the transhepatic approach to biliary access?

Liver abscess Signup and view all the answers

What is a potential complication that can occur from a transhepatic biliary access procedure?

Pleural contamination Signup and view all the answers

Which imaging technique is commonly utilized in the assessment of biliary tract interventions?

CT scan Signup and view all the answers

What is a notable advantage of percutaneous cholecystostomy in high-risk patients?

Lower risk of postoperative complications Signup and view all the answers

In the context of urgent biliary procedures, which factor is critical for evaluating the effectiveness of percutaneous interventions?

Rate of bile peritonitis Signup and view all the answers

What is a primary reason for performing percutaneous cholecystostomy in high-risk patients?

To effectively manage acute cholecystitis Signup and view all the answers

Which method is commonly utilized for biliary access in patients during percutaneous interventional procedures?

Ultrasound-guided biliary drainage Signup and view all the answers

What is a common complication associated with percutaneous cholecystostomy procedures?

Hemorrhage at the puncture site Signup and view all the answers

In the context of interventional radiology, what is the primary purpose of performing diagnostic imaging of the biliary tract?

To visualize gallstones and bile duct obstructions Signup and view all the answers

What role does a locking trocar play in percutaneous cholecystostomy procedures?

It ensures the stability of the catheter once inserted Signup and view all the answers

What is indicated by wall thickening of the gall bladder in ultrasound images?

Gall bladder infection or inflammation Signup and view all the answers

Which anatomical structures are visualized adjacent to the gall bladder in a typical ultrasound?

Liver and large bowel Signup and view all the answers

What complication might occur when attempting to access the gall bladder with a dilator?

Bending of the dilator due to insufficient tissue support Signup and view all the answers

During the procedure, which structure could indicate a failure to pass the wire appropriately?

Wire buckling at the cystic duct origin Signup and view all the answers

What does the fluoroscopic caption during a cholecystostomy primarily indicate?

Correct placement of the gall bladder drain Signup and view all the answers

What is a key indication for using CT instead of ultrasound in the context of calcular cholecystitis?

Significantly diseased gallbladder with wall thickening Signup and view all the answers

When performing a cholecystostomy, what gauge needle is commonly utilized if the operator prefers a low-caliber approach?

20- to 22-gauge needle Signup and view all the answers

What is the first step in the procedure before catheter insertion during a cholecystostomy?

Needle placement under ultrasound guidance Signup and view all the answers

What role does using a 0.035-inch wire serve after needle placement in a cholecystostomy procedure?

To guide the catheter insertion securely Signup and view all the answers

Why might an operator prefer using ultrasound over fluoroscopy for the initial stages of cholecystostomy?

Ultrasound avoids ionizing radiation exposure. Signup and view all the answers

What is the first-line treatment for pain management in acute cholecystitis?

Opiates such as morphine Signup and view all the answers

Which imaging technique is commonly indicated for diagnosing acute cholecystitis?

Ultrasound Signup and view all the answers

What is routinely administered to all patients diagnosed with acute cholecystitis?

Antibiotics targeting gram-negative bacteria and anaerobes Signup and view all the answers

What is the primary surgical intervention for treating acute cholecystitis?

Laparoscopic cholecystectomy Signup and view all the answers

Which condition may warrant emergent surgery in patients with acute cholecystitis?

Sepsis or hemodynamic instability Signup and view all the answers

What imaging finding indicates the possibility of gallbladder gangrene and perforation in acute cholecystitis?

Interrupted rim sign Signup and view all the answers

What is one of the factors limiting the use of MR imaging for diagnosing acute cholecystitis?

Longer scan times and higher costs Signup and view all the answers

Which surgical approach has shown a recent trend toward earlier intervention for acute cholecystitis?

Laparoscopic cholecystectomy Signup and view all the answers

What is a significant complication associated with the treatment of acute cholecystitis using antibiotics?

Infection recurrence Signup and view all the answers

In patients with suspected biliary obstruction due to choledocholithiasis, which imaging technique is indicated?

MR cholangiopancreaticography Signup and view all the answers

What should be the target INR before performing a procedure with a high risk of bleeding?

1.5 to 1.8 Signup and view all the answers

Which imaging modality is preferred for cholecystostomy tube placement due to its speed and cost-effectiveness?

Ultrasound Signup and view all the answers

Which complication is most commonly associated with procedures involving the gallbladder?

Infection Signup and view all the answers

What is the reasoning behind administrating morphine during cholescintigraphy?

To increase sphincter of Oddi pressure Signup and view all the answers

When preparing for cholecystostomy, which laboratory investigation is crucial for determining patient stability?

Platelet count Signup and view all the answers

Which laboratory investigation is essential to rule out complications of acute cholecystitis?

Serum lipase and amylase Signup and view all the answers

What is one serious complication that can occur in acute cholecystitis, affecting mortality rates?

Gallstone ileus Signup and view all the answers

What diagnostic imaging technique is less sensitive than ultrasound for detecting gallbladder wall thickening in acute cholecystitis?

MRCP Signup and view all the answers

According to the Tokyo Guidelines, what imaging findings are required to diagnose acute cholecystitis?

Imaging findings characteristic of acute cholecystitis plus clinical signs Signup and view all the answers

What is the recommended management for Grade I acute cholecystitis according to the updated Tokyo Guidelines?

Early laparoscopic cholecystectomy in low-risk patients Signup and view all the answers

What is a primary indication for performing a percutaneous cholecystostomy?

Patients unsuitable for general anesthesia and surgery Signup and view all the answers

How do complication rates compare between percutaneous cholecystostomy (PC) and open cholecystectomy for high-risk patients?

PC is likely to display spuriously high complication rates due to underlying patient conditions Signup and view all the answers

What recent advancement in technique may reduce the necessity for percutaneous cholecystostomy?

Improvements in laparoscopic cholecystectomy techniques Signup and view all the answers

Which aspect of clinical guidelines for acute cholecystitis remains controversial?

The definition of acute cholecystitis severity Signup and view all the answers

How do comorbidities typically influence treatment decisions in patients requiring cholecystostomy?

They significantly increase the risks associated with any surgical intervention Signup and view all the answers

How do complication rates compare between patients treated with percutaneous cholecystostomy and those undergoing cholecystectomy?

Cholecystectomy has significantly lower complication rates. Signup and view all the answers

Which approach is considered first-line treatment for acute calculous cholecystitis?

Laparoscopic cholecystectomy. Signup and view all the answers

What is a significant limitation of using retrospective studies in evaluating cholecystostomy efficacy?

They lack well-defined clinical presentation metrics. Signup and view all the answers

How do comorbidities impact treatment decisions for patients with acute cholecystitis?

Comorbidities may lead to consideration of less invasive treatments. Signup and view all the answers

What was the major finding of the 1994 study regarding the transperitoneal approach for cholecystostomy?

It showed safe placement of catheters without complications. Signup and view all the answers

In the comparison of approaches studied by Loberant et al., what conclusion was drawn regarding complications?

There were no significant differences in complication rates between approaches. Signup and view all the answers

What is a potential patient safety outcome when using the trocar technique for cholecystostomy?

Reduced incidence of infection. Signup and view all the answers

Which coagulation parameter was found to be similar in both groups studied by Garber et al.?

International normalized ratio Signup and view all the answers

What characteristic is more commonly associated with the trocar technique compared to the Seldinger technique during percutaneous cholecystostomy?

Larger catheter size Signup and view all the answers

Which complication may arise specifically from the transhepatic approach to biliary access?

Increased bleeding risk post-procedure Signup and view all the answers

What significant difference was noted between the trocar and Seldinger techniques regarding post-procedure outcomes in percutaneous cholecystostomy?

Trocar technique was associated with higher early post-procedure hemorrhage Signup and view all the answers

What is a potential complication associated with the trocar technique in interventional radiology?

Increased risk of accidental vascular injury Signup and view all the answers

In post-procedural care after percutaneous cholecystostomy, which of the following is least likely to be monitored?

Recovery of gallbladder function Signup and view all the answers

What is the primary imaging modality used for planning the insertion route in percutaneous cholecystostomy?

Computed Tomography (CT) Signup and view all the answers

What is a significant advantage of using color Doppler assessment during percutaneous cholecystostomy?

To prevent accidental vascular injury Signup and view all the answers

What is a significant precaution to consider when performing a percutaneous cholecystostomy via the intercostal route?

Avoiding excessive iodinated contrast to prevent chemical cholangitis. Signup and view all the answers

Which imaging modality is primarily used for percutaneous cholecystostomy when sonographic visualization is poor?

CT guidance Signup and view all the answers

What is a potential complication associated with improper catheter placement during percutaneous cholecystostomy?

Fistula formation Signup and view all the answers

How is a pigtail catheter introduced after initial guidewire placement in a percutaneous cholecystostomy?

By advancing over a stiff guidewire. Signup and view all the answers

What is one of the main goals when performing serial dilatation of the percutaneous tract?

To allow for placement of larger catheters. Signup and view all the answers

Study Notes

Quality Improvement Guidelines for Percutaneous Transhepatic Cholangiography, Biliary Drainage, and Percutaneous Cholecystostomy

The Society of Interventional Radiology (SIR) Standards of Practice Committee produced these guidelines. Committee members are experts in interventional procedures.
Consensus is defined as 80% agreement amongst Delphi participant group members.
Guidelines are reviewed by the Revisions Subcommittee.
The documents undergo a 30-day comment period for feedback from SIR members.
The SIR Executive Council endorses the document before publication.

Methodology

The SIR uses a process for producing standards documents.
Standards of relevance and timeliness are conceptualized by the Standards of Practice Committee.
A recognized expert is designated as the primary author.
A comprehensive literature search utilizes electronic databases.
Peer-reviewed articles are critically assessed, evaluating methodology, results, and conclusions.
Evidence is compiled into tables for evaluation.
Consensus is achieved through a modified Delphi method among a minimum of 12 committee members if evidence is weak, conflicting, or contradictory.

Introduction

Percutaneous transhepatic cholangiography is a safe and effective procedure for evaluating biliary abnormalities.
It reliably shows the level of abnormalities.
It can sometimes help determine the etiology of the abnormalities.
Percutaneous transhepatic biliary drainage is a primary or palliative treatment of biliary abnormalities and can be used to help with treatment of many abnormalities revealed by cholangiography.
Percutaneous cholecystostomy is effective for decompressing the gallbladder to manage cholecystitis.
These guidelines are intended for quality improvement initiatives and to help assess percutaneous transhepatic procedures.

Definitions

Percutaneous transhepatic cholangiography involves sterile needle insertion into peripheral biliary radicles, guided by imaging. Contrast administration delineates the biliary anatomy/pathology.
Percutaneous transhepatic biliary drainage involves sterile cannulation of a peripheral biliary radicle, guided by imaging, to create a pathway for treatment. Drainage through a tube or stent completes the procedure.
Percutaneous cholecystostomy involves needle placement into the gallbladder for bile aspiration; a tube is often added for external drainage.

Indications and Contraindications

Indications for each procedure are listed in tables 1-3.
Thresholds for indications are 95%.
Coagulopathy is a relative contraindication.