alexa A Novel Analgesic Approach for Percutanoeus Transhepatic Biliary Drainage | Open Access Journals
ISSN: 2155-6148
Journal of Anesthesia & Clinical Research
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A Novel Analgesic Approach for Percutanoeus Transhepatic Biliary Drainage

Sachidanand Jee Bharati1*, Mukesh Yadav2 and Vinod Kumar1

1Onco Anaesthesia & Palliative Medicine, DR BRAIRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India

2Radiology, DR BRAIRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India

*Corresponding Author:
Sachidanand Jee Bharati
Assistant Professor
Onco Anaesthesia & Palliative Medicine
DR BRAIRCH
All India Institute of Medical Sciences (AIIMS)
New Delhi, India
Tel: 9968436042
E-mail: [email protected]co.in

Received date: March 05, 2016; Accepted date: May 29, 2016; Published date: June 03, 2016

Citation: Bharati SJ, Yadav M, Kumar V (2016) A Novel Analgesic Approach for Percutanoeus Transhepatic Biliary Drainage. J Anesth Clin Res 7:628. doi:10.4172/2155-6148.1000628

Copyright: © 2016 Bharati SJ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Letter to the Editor

In developing world, malignant tumours of pancreas and gall bladder usually present very late with bile duct obstruction. The clinical presentation in such cases is epigastric pain and progressively increasing jaundice. In any stage of disease, biliary obstruction has to be relieved with external drainage. Percutanoeus trans hepatic biliary drainage (PTBD) is the procedure of choice and is done by interventional radiologist under local anaesthesia [1]. As any interventional procedure under image guidance needs patient immobility and cooperation especially if done under LA. Catastrophic complications related to PTBD were reported in literature including bleeding, sepsis, acute pancreatitis, intrahepatic haematoma, and gut perforation [2]. Also, pain is the most common complaint in the post procedure period. As there is no standard anaesthetic technique described in literature for PTBD, we would like to share our experience using subcostal trans versus abdominis plane (TAP) block for PTBD.

A 42 year cachexic male, diagnosed with carcinoma head of pancreas was planned for PTBD. He had jaundice with conjugated hyperbilirubinemia having bilirubin levels of 21 mg. After a written informed consent, it was planned to do the PTBD under LA. The right sided subcostal approach for PTBD was attempted but because of pain at the puncture side, patient became uncooperative and procedure was abandoned. The case was discussed and reviewed by consultant anesthesiologist for doing the procedure under general anaesthesia. Considering the poor general condition and elevated bilirubin levels, it was decided to do PTBD under ultrasound (US) guided oblique subcostal TAP (OSTAP) block. After attaching all the standard monitors, OSTAP block was given under US guidance. Plane of block between rectus abdominis and transversus abdominis was confirmed using hydro dissection technique, 20 ml of 0.25% plain ropivacaine was injected after negative aspiration [3]. The procedure was started after testing sensory block with pin prick and was completed without any complaints of pain. The total procedure time was 30 min. The pain score on numerical rating scale was 2 out of 10 at the end of procedure. Patient was followed up in the post procedure period, his pain score and any other complications for next 24 hours were noted. The average pain score in the post procedure period was 2/10 on NRS. He was discharged after 24 hours of observation.

Ultrasound guided approach for TAP block was first described by Hebbard [4]. Since then it is being used for intraoperative and postoperative anaesthesia and analgesia in lower abdominal surgeries. The technique involves real time injection of local anesthetic under US guidance into the plane between the transversus abdominis and the internal oblique muscles to block the thoracolumbar intercostal nerves.

The oblique subcostal TAP block is a modification of classical TAP block with advantage that it can provide upper abdominal wall analgesia blocking T7-L1 dermatomes. It can easily be performed under US guidance by identifying plane between the rectus abdominis and transversus abdominis muscle near the costal margin [4].

Hence, US guided oblique sub costal TAP block is an effective anaesthetic technique for drainage procedures performed on upper abdomen. It can be safely used in PTBD procedure where general anaesthesia is risky because of deranged liver functions.

References

  1. Otto MD, Johan SL (2008) Percutaneous drainage and stenting for palliation of malignant bile duct obstruction. EurRadiol 18: 448-456.
  2. Weber A, Gaa J, Rosca B, Born P, Neu, et al. (2009) Complications of Percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts. Eur J Radiol 72: 412-417.
  3. Hebbard PD, Barrington MJ, Vasey C (2010) Ultrasound-guided continuous oblique subcostal transversus abdominis plane blockade: description of anatomy and clinical technique. RegAnesth 35:436-441.
  4. Hebbard P, Fujiwara Y, Shibata Y, Royse C (2007) Ultrasound guided transversus abdominis plane block. AnaesthIntensCare 35: 616-617.
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Review summary

  1. Nathan Lewis
    Posted on Aug 30 2016 at 2:42 pm
    The article is highly informative and provides extensive knowledge on percutaneous transhepatic biliary drainage. However, given the complexity of the condition it is not possible to conclude that OSTAP block described in the paper can be directly used in clinical cases on the basis of the results of one case. It would be recommended that the authors should report case series of the patients who underwent PTBD under the same anesthetic procedure and describe the details of OSTAP block.
 

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