The clinical value of dual contrast-enhanced ultrasound in PTCD in patients with biliary obstruction

The clinical value of dual contrast-enhanced ultrasound in PTCD in patients with biliary obstruction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The clinical value of dual contrast-enhanced ultrasound in PTCD in patients with biliary obstruction Longli Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6605022/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To evaluate the clinical value of double contrast enhanced ultrasound (D-CEUS) in percutaneous transhepatic cholangial drainage (PTCD) in patients with biliary obstruction.Try to evaluate the clinical significance of double contrast enhanced ultrasound (D-CEUS) in catheterization and drainage of patients with biliary obstruction . Methods 29 patients with biliary obstruction underwent catheterization and drainage under the guidance of conventional ultrasound (US). Among them, 15 patients underwent double contrast enhanced ultrasound (D-CEUS), which includes transvenous contrast enhanced ultrasound (CEUS) and ultrasonic cholangiography (USC), were set as group B (experimental group), postoperative drainage and poor yellow reduction were guided by double contrast enhanced ultrasound (D-CEUS); the remaining 14 patients were were randomized as control (group A) without other operations. Results The bile drainage volume of patients in group A was lower than that of group B at 1, 3, and 7 days after receiving biliary drainage, and the difference between the two groups was statistically significant ( F = 16.085, P < 0.05). The total bilirubin, γ-GT, and ALT in group A were higher than those in group B, and the difference between the two groups was statistically significant ( P < 0.05). There were 5 patients in group A who failed to insert the tube and the position of the tube was poor (5/14 (35.71%)), and all 15 patients in group B were successful in one-time catheterization (15/15 (100%)), and the difference between the two groups was statistically significant ( χ 2 = 8.413, P <0.05). Six patients in group A had postoperative complications, and there was only one patient in group B, and the difference between the two groups was statistically significant ( χ 2 = 5.585, P < 0.05). Conclusion double contrast enhanced ultrasound (D-CEUS) can effectively perform preoperative lesion assessment, intraoperative catheter placement navigation, and postoperative auxiliary adjustment for biliary obstruction patients undergoing percutaneous transhepatic cholangial drainage (PTCD), which effectively improving the efficiency of reducing yellowing. Percutaneous transhepatic cholangial drainage Dual contrast enhanced ultrasound Biliary obstruction Ultrasonic cholangiography Contrast enhanced ultrasound Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Bile duct placement and drainage is significant for palliative reduction of yellowness in patients with malignant biliary obstruction [ 1 ], radical surgical treatment and improvement of liver function before radiotherapy [ 2 ].Routine ultrasound-guided percutaneous transhepatic cholangial drainage (UG-PTCD) is favored by clinicians and patients because of its safety, convenience, and ability to be performed at the bedside in real time. However, there is a lack of scientific and perfect guidance evaluation system for bile duct placement and drainage, and the effect of yellowing reduction and drainage in some patients cannot be followed and adjusted for a long time.In this study, we retrospectively analyzed patients who underwent D-CEUS, in other words, CEUS and USC monitoring and modulation, to evaluate the value of D-CEUS in PTCD in patients with biliary obstruction in our hospital with ultrasound-guided biliary drainage. Materials and Methods Patient information Nineteen patients with surgical pathology or clinically confirmed diagnosis of hilar cholangiocarcinoma, one patient with intrahepatic cholangiocarcinoma, one patient with gallbladder cancer invading the liver parenchyma, and eight patients with pancreatic head cancer who underwent PTCD at the Ultrasound Medical Center of our hospital from October 2018 to January 2020.All patients were divided into two groups A and B. In group A, US-guided PTCD drainage and late monitoring were performed in 7 males and 7 females, aged 37 to 72 years, with a mean age of (60.6 ± 7.7) years, while in group B, D-CEUS-guided PTCD drainage and late monitoring were performed in 8 males and 7 females, aged 35 to 73 years, with a mean age of (60.9 ± 6.8) years.There was no statistical difference in the general condition of the patients before treatment between the two groups (P > 0.05)(Table 1 ).Inclusion criteria: patients who underwent UG-PTCD alone and patients who also underwent D-CEUS examination and evaluation with complete imaging and laboratory data. Exclusion criteria: patients with obstruction, occupying US that cannot be demonstrated, patients with obstructive jaundice operated by multiple biliary drainage modalities at the same time, and incomplete imaging and laboratory investigations.Finally 29 patients with obstructive jaundice with 34 drainage tubes were included in this study. The study was conducted in accordance with the principles of the Declaration of Helsinki,and the study protocol was approved by the ethics committee of Second Hospital of Lanzhou University.Because of the retrospective nature of the study,patient consent for inclusion was waived Table 1 Comparison of the two groups of patients before drainage. Group Gender age TBIL(umol/L) γ-GGT(U/L) ALT(U/L) male Female A (n = 14) 7 7 60.6 ± 7.7 293.8 ± 113.3 670.4 ± 230.3 165.1 ± 62.4 B (n = 15) 8 7 60.9 ± 6.8 296.6 ± 128.0 663.9 ± 235.8 164.9 ± 55.3 χ2/t 0.032 1.000 -0.243 0.809 0.059 0.954 -0.072 0.943 0.009 0.993 P Apparatus and methods EPIQ 7 and LOGIQ E9 color Doppler ultrasound diagnostic instruments were applied, equipped with probes C5-1, X6-1, C6-1, and probe frequencies of 1–5 MHZ, and cholangiography was performed using a specific low mechanical index contrast technique with mechanical index ≤ 0.2. The ultrasound contrast agent is SonoVue (Bracco, Italy), which is diluted by adding 5 ml of 0.9% saline to each drug according to the instructions and shaken vigorously to form a suspension. There is no standard dose of intracorporeal contrast agent, which varies according to the type, size and location of the examined cavity [ 3 , 4 ], according to a ratio of 1:200, i.e., every 0.1 ml of SonoVue suspension is added to 20 ml of warm saline for dilution. 20 ml of warm saline was diluted, and each dosage was 20–100 ml, which was injected through the drainage tube,CEUS 2.4 ml of suspension was injected directly in the group along the elbow vein. All patients underwent routine ultrasound whole abdominal exploration to understand the shape of the lesion at the site of obstruction and its relationship with the bile duct wall and the degree of bile duct obstruction, as well as to observe the anatomical alignment of the biliary tree, the bile duct tortuosity, the extent and degree of dilatation, and to staging patients with cholangiocarcinoma of the hilar region according to the Bismush-Corlette staging [ 5 ]. Patients in group A underwent US assessment only before PTCD, while patients in group B underwent CEUS after routine ultrasonography, focusing on the mode of enhancement of the lesion, the relationship between the lesion and the biliary tract lumen and wall, and the degree of biliary obstruction. In patients without any biliary drainage operation, PTCD was performed under US guidance in group A. In group B, ultrasound-guided PTCD was performed after CEUS, and if necessary, PTCD was performed under D-CEUS guidance, and the operation images were retained to decide the placement method with reference to the dilated course of the confluent bile duct of the obstructed lumen and its relationship with the common bile duct and the degree of biliary obstruction. In patients with biliary lumen occupancy, the nature of the biliary lumen occupancy and its relationship with the bile duct wall were also one of the considerations in deciding the placement method. Patients in group B after PTCD operation were first decompressed by slowly withdrawing an appropriate amount of bile through the drainage tube under conventional ultrasound surveillance (20–100 ml was routinely withdrawn) and measured. The patient was then asked to hold his breath and slowly injected along the drainage tube in ultrasonography mode, and a more complete view of the biliary tree and the obstruction site was selected (usually the right side of the subxiphoid process or the right intercostal probe facing the hepatoportal area) for video recording. Patients with poor drainage in group A underwent US review assessment, also every two days. The patients' clinical symptoms, drainage fluid properties and values of total bilirubin, drainage bile volume, γ-glutamyl transferase (γ-GT) and glutathione aminotransferase (ALT) 1 day before and 1 day, 3 days and 7 days after drainage were recorded daily after the operation. Statistical method SPSS 25.0 statistical software was used, and the chi-square test or Fisher's exact probability method was used for counting data, and (x ± s) was used for measurement data, in which bile drainage, total bilirubin, γ-GT, and ALT were analyzed by one-way ANOVA with repeated measurements, and differences were considered statistically significant at P < 0.05. Using R4.1.1 to make group scatter plots of total bilirubin, γ-GT, ALT and bile drainage after PTCD. Result The bile drainage in group B was higher than that in group A, and the difference was statistically significant (P < 0.05). The serum total bilirubin, γ-GT and ALT levels were lower than those in group A, and the difference was statistically significant (P < 0.05)(Table 2 and Fig. 1 ). Table 2 The drainage and liver biochemical indicators of the two groups of patients. Related indicators Detection time A B F P Drained bile volume(ml) Day 1 312.9 ± 46.2 424.3 ± 128.3 16.085 <0.001 Day 3 278.1 ± 49.9 426.4 ± 94.4 Day 7 242.4 ± 42.0 464.3 ± 97.9 TBIL(umol/L) Day 1 236.7 ± 125.7 192.4 ± 99.2 3.154 0.012 Day 3 202.0 ± 125.6 133.4 ± 85.6 Day 7 168.5 ± 121.3 92.3 ± 79.8 γ-GT(U/L) Day 1 595.1 ± 239.2 518.7 ± 224.4 7.721 <0.001 Day 3 429.7 ± 258.4 301.5 ± 191.6 Day 7 253.6 ± 233.1 164.5 ± 148.4 ALT(U/L) Day 1 159.4 ± 61.8 128.7 ± 54.5 10.603 <0.001 Day 3 125.0 ± 55.1 81.8 ± 36.7 Day 7 90.8 ± 44.0 41.3 ± 20.6 In the group of 14 patients, preoperatively, US found one case of complete obstruction of the secondary bile duct, three cases of complete obstruction of the primary bile duct, two cases of incomplete obstruction, five cases of complete obstruction of the extrahepatic bile duct, and three cases of incomplete obstruction. Among them, there were 3 cases of left and right lobe obstruction, 1 case was successfully given bilateral catheterization, and the other 2 cases were only catheterized on the opposite side due to the failure of one bile duct puncture (1 case had no bile duct dilatation 2 days after operation, which proved that the left and right lobes were connected, and no additional Catheterization, another case found bile duct dilatation 2d after operation, and catheterization was repeated).The left and right lobes were connected in 11 cases, and 4 cases were unable to deliver the guide wire to the obstructive segment because of multiple small partitions in the selected target bile duct.In group A, there were 5 patients (5/14 (35.71%)) with failed catheter placement and poor placement of the catheter, and 15 patients in group B had successful catheter placement at one time (15/15 (100%)). The difference between groups was statistically significant ( χ2 = 8.413, P < 0.05).In group B, one case of complete obstruction of tertiary bile ducts, 3 cases of complete obstruction of primary bile ducts, 10 cases of complete obstruction of extrahepatic bile ducts and one case of incomplete obstruction were found in preoperative US.One case of incomplete obstruction of tertiary bile ducts, 2 cases of incomplete obstruction of primary bile ducts, one case of complete obstruction, 5 cases of complete obstruction of extrahepatic bile ducts, and 6 cases of incomplete obstruction were confirmed by D-CEUS.In one patient, preoperative conventional ultrasound thought that the target bile duct was completely obstructed, and the distance from the puncture point to the obstruction site was too small, and the drainage range was limited, so it was considered unsuitable for PTCD drainage.On the other hand, CEUS and USC both showed incomplete obstruction. The drainage tube was successfully placed, and the postoperative drainage was smooth.(Fig. 2 ).Both the left and right lobe bile ducts were found to be blocked by conventional ultrasound in 2 patients, and bilateral catheters were required. After catheter placement, USC assessment showed that both left and right lobe bile ducts were visualized, and no additional catheter placement was required (Fig. 3 ).Only one case of USC evaluation also required bilateral placement of drains, and 11 cases with left and right lobe communication were successfully delivered to the extrahepatic bile duct under real-time USC guidance (Fig. 4 ), with postoperative USC suggesting total hepatic drainage. Among the patients in Group A, one patient developed transient bloody bile after PTCD due to a misjudgment of the extent of tumor invasion of the bile ducts, suspicion of touching the tumor in the duct lumen during puncture, and in one patient, bile leakage complication occurred due to the target bile duct being too thin and the head end of the drainage tube could not be monitored accurately and in real time, and the drainage tube was later successfully placed via US-guided transfer several times.One patient showed periductal ooze 4 d after surgery, suspected to be drainage tube blockage, and the drainage condition was acceptable after flushing. 3 patients had postoperative abdominal pain with reduced drainage, and the dilatation of the intrahepatic bile duct was reduced on US exploration, and the drainage tube was in place, so anti-inflammatory and analgesic symptomatic treatment was given, and the symptoms were slightly relieved.One patient in group B developed acute symptoms such as chills, high fever, and severe abdominal pain 1 week after drainage due to acute cholecystitis. The perforation of acute cholecystitis was confirmed by USC, and ultrasound-guided puncture and fluid extraction were performed in one patient. Two days after the operation, the drainage volume suddenly decreased, accompanied by abdominal pain, which continued to aggravate. It was confirmed by USC that the side hole of the drainage tube was partially prolapsed (Fig. 5 ). There was a statistically significant difference in postoperative complications between groups A and B ( χ2 = 5.585, P < 0.05) (Table 3 ) Table 3 Comparison of complications and differences in drainage volume after drainage between the two groups. Group Postoperative bloody bile Postoperative bile leak Postoperative peritubular exudate abdominal pain total A (n = 14) 1(7.14%) 1(7.14%) 1(7.14%) 3(21.43%) 6(42.86) B (n = 15) 0 0 0 1(6.67%) 1(6.67%) χ2 5.585 P 0.035 Discussion Hilar cholangiocarcinoma is usually found in the middle or late stage due to the special anatomical location, the chaotic and complex surrounding vascular structure, and the lack of obvious clinical symptoms.Surgery is the only possible way to cure hilar cholangiocarcinoma, but the surgical conditions are demanding. If multiple bile ducts and blood vessels in the liver are invaded, it will be inoperable, and PTCD plays an important role in both preoperative yellowing reduction and palliative hepatoprotective drainage treatment.Tang et al [ 6 ] concluded by meta-analysis that especially in patients with Bismush-Corlette type II, III or IV, PTCD should be used as an initial method of biliary drainage in order to reduce the incidence of surgery-related cholangitis, pancreatitis and to improve the palliative palliative treatment aspect of cholestasis.However, there is a lack of accurate and effective preoperative placement decision evaluation system for PTCD; there is a lack of complete postoperative drainage follow-up evaluation system, which is detrimental to the improvement of patient survival quality and better preoperative yellowing reduction and postoperative protection of residual liver function. In this study, we found that the overall bile drainage in group A was lower than that in group B on days 1, 3 and 7 after biliary drainage, and there was a significant difference between the two groups ( P < 0.05).Total bilirubin, γ-GT and ALT in group A were generally higher than those in group B. There was a significant difference between the two groups ( P < 0.05).The main reason for the lower drainage in group A than in group B may be that the end of the drainage tube was not placed at the optimal drainage point.In order to obtain the best drainage, the drainage tube must be located downstream of the confluence of multiple unobstructed bile duct tributaries, so as to achieve the effect of "all rivers in the sea".Wang et al [ 7 ] reported that the drainage flow was closely related to the cross-sectional area of the drainage duct, length, length and location of the drainage duct in the bile duct, and with low obstruction, the lateral hole of the drainage duct was located in the common bile duct than in the left and right hepatic ducts. Preoperative CEUS for PTCD enables accurate Bismush-Corlette typing of the porta hepatis, the degree of biliary obstruction, the identification of biliary mud deposits in the bile ducts from other occupancies, and the relationship between the extent of both and the bile duct wall to better guide the selection of target bile ducts for punctal drainage. Intraoperative real-time biliary ultrasonography guidance also allowed for a more visual observation of the draining bile ducts, which explains why all 15 patients in group B were successfully placed in one visit (15/15 (100%)) and the difference in placement success rate between groups A and B was statistically significant ( χ2 = 8.413, P < 0.05).Conventional ultrasound often cannot track the catheter in real time and requires high operator skill and experience, while the accuracy of percutaneous transhepatic cholangiography (PTC) in determining the cause of obstruction has been reported in the literature to be only 63%, USC improves the visualization of the catheter tip and can accurately define the level of biliary obstruction up to 100% [ 8 ].USC is well suited to observe the fifth-order branches of the biliary tree and is therefore considered as an alternative to radiological PTC [ 9 , 10 ].Chandra et al [ 11 ] concluded that intraoperative ultrasound using saline as a contrast agent is significant for biliary surgery as an inexpensive and concise navigation modality that can accurately visualize isolated small bile ducts in the liver.After PTCD, the bile duct is significantly less dilated or even non-dilated, and it is difficult for US to determine the location and status of the end of the drain due to the lack of a hypoechoic acoustic window; however, USC improves visualization of the biliary system, especially in the undilated bile duct system [ 12 ].USC allows for clearer observation of the drainage tube alignment, the presence or absence of folding at the end, the number of draining branch bile ducts, and the extent of the liver lobe covered, providing real-time guidance for duct adjustment (Figs. 6 ).Similarly, USC was found to be able to accurately show the drain alignment and end position with better results than US, and to assess the extent of drainage and reduce the incidence of complications such as poor drainage and bile leakage after PTCD [ 13 , 14 ].Total bilirubin, gamma-glutamyl transferase, and glutamyl transaminase were generally higher in group A than in group B after drainage probably because of the following deficiencies in US compared to D-CEUS: 1. The extent of drainage cannot be judged, and often only a few branches or 1 branch of the left or right lobe is drained, which does not improve the overall liver function.2. After the position of the lateral orifice of the drainage tube is removed from the optimal drainage site, although the drainage flow may remain temporarily unchanged, the segment of the liver that actually needs drainage most to improve liver function fails to receive advantageous drainage.3. D-CEUS allows regular inspection and identification of bile sludge deposited in the bile duct, which is more acute and reliable than direct visual observation of the viscosity and other properties of the drained bile to determine the time of flushing.It has been reported that CEUS can help differentiate benign and malignant causes of obstructive jaundice, improve the detection of bile duct infiltration in liver tumors, and allow better assessment of the internal blood supply and extension of hilar hepatobiliary tumors [ 15 ].The incidence of complications after PTCD in group A was significantly higher than that in group B, and there was a significant statistical difference between the two groups ( χ2 = 5.585, P < 0.05), which may be due to the following points:D-CEUS can evaluate the nature of the lesions in the obstructed bile duct before operation, detect the position of the puncture needle tip and the position of the drainage tube after the catheter placement, avoid touching the accompanying blood vessels around the bile duct, and the rich blood supply tumor in the bile duct to cause hemorrhage or bloody bile, reduce the incidence of bile leakage caused by puncture needle and drainage tube breaking through the anterior and posterior walls of the bile duct or exiting into the liver parenchyma.In addition to PTCD, the use of USC during thermal ablation of tumors was found to protect the bile ducts [ 16 ], and similarly, CEUS can provide valuable information for surgical decision making during surgery for hepatoportal cholangiocarcinoma [ 17 ]. Conclusion CEUS is valuable for preoperative assessment, placement decision and postoperative transfer of PTCD, which reduces postoperative complications of PTCD and improves the success rate to some extent. Declarations Conflicts of Interest The authors declare no conflicts of interest. Funding Not applicable. Institutional Review Board Statement : This is a retrospective study that complies with the Declaration of Helsinki and does not require ethical review. Informed Consent Statement : Not applicable. Conflicts of Interest : The author declare no conflict of interest. Author Contribution Longli Wang completed the data collection and statistical analysis, and finally wrote this article References Ma J, Luo J, Gu J, et al. Malignant obstructive jaundice treated with intraluminal placement of Iodine-125 seed strands and metal stents: An analysis of long-term outcomes and prognostic features. Brachytherapy 2018;17(4): 689–695. Moole H, Bechtold M, Puli S R. 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Intraoperative contrast-enhanced ultrasound can have a crucial role in surgical decision-making during hepato-pancreatico-biliary surgery - Analysis of impact and input. Clin Hemorheol Microcirc 2021;78(1):103–116. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6605022","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486424089,"identity":"e2d9c27f-413e-4997-b06f-5b3e41486e4a","order_by":0,"name":"Longli Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYBACefbmgw8k/9jU87M3EKnFsOdYsoFlQ1qCZM8BYq25kaMmUNlwOMHgRgKROhhn5LAx3NyRlsdw8/HGGww1NtEEtbDzvD32cOYZm2LG2WnFFgzH0nIbCNrSnpduLMGWxtgsnWMmwdhwmLAWhgM5ZtJ/2A4ztkmeIVbLCaDhkm2HE3skeIjUAg5kiTNpxhI8QL8kEOMXcFRKVNjI2R8/vPHGhxobIhyGBAwkEkhRDtFCqo5RMApGwSgYGQAAYBdDfbDxNkwAAAAASUVORK5CYII=","orcid":"","institution":"The First Affiliated Hospital of Xi 'an Medical University","correspondingAuthor":true,"prefix":"","firstName":"Longli","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-05-06 16:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6605022/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6605022/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87362776,"identity":"e8507b30-fceb-41ee-99d8-b62bf5740b77","added_by":"auto","created_at":"2025-07-23 05:57:11","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":227911,"visible":true,"origin":"","legend":"\u003cp\u003eA shows the distribution of the difference between γ-glutamyltransferase and total bilirubin on days 1 and 7 after PTCD in groups A and B. B shows the distribution of the mean bile drainage and the difference between glutamate transaminase on days 1, 3 and 7 after PTCD in both groups.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6605022/v1/b11ad5d1659d2e466c43c646.jpeg"},{"id":87363348,"identity":"fdfc18ce-85fd-413e-9ea6-97db3e76954e","added_by":"auto","created_at":"2025-07-23 06:05:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":396373,"visible":true,"origin":"","legend":"\u003cp\u003eA 70-year-old male with portohepatic bile duct cancer A: US showed complete obstruction at the left lobe hepatic duct bifurcation; B: right US showed complete obstruction of the lower left external bile duct and invasion of the upper left external bile duct resulting in complete obstruction; left CEUS showed incomplete obstruction of the upper and lower left external lobe bile ducts with poor luminal sound transmission; C: ultrasound-guided PTCD (UG-PTCD) showed puncture and drainage of the lower left external bile duct using a one-step method; D and E: USC and 3D-USC after PTCD showed good drainage of the left lobe of the liver, and both upper and lower left external lobe bile ducts were visualized.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6605022/v1/db7a512b3ff823a4b3acd870.png"},{"id":87362787,"identity":"8de76eb1-93ba-42e8-bd1a-2290cc645cd4","added_by":"auto","created_at":"2025-07-23 05:57:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":694861,"visible":true,"origin":"","legend":"\u003cp\u003eA 51-year-old female patient with intrahepatic bile duct cancer. A: US shows a slightly hypoechoic mass in the right lobe of the liver with regular morphology and indistinct borders (thin black arrow), with a rod-like blood flow signal inside and a flow resistance index of 0.53, and a peripheral dilated bile duct with tortuous travel, which is interrupted below the lesion. B: CEUS shows a large hyperenhancing mass in the right lobe of the liver (black dashed line), with a larger extent of enhancement than US (blue dashed line), and a heterogeneous enhancement inside the lesion, with a significantly dilated bile duct in the left lobe of the liver interrupted below the lesion, and the remaining bile ducts are not significantly dilated. F: MRCP shows that most of the intrahepatic bile ducts are visualized, while the end of the branch bile ducts in the right anterior lobe of the liver are poorly visualized and interrupted (white triangle).\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6605022/v1/40fe3d348d978b4b94a25414.png"},{"id":87363346,"identity":"17bf7d59-e08b-4308-bad7-983a758a424e","added_by":"auto","created_at":"2025-07-23 06:05:11","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":270762,"visible":true,"origin":"","legend":"\u003cp\u003eA 58-year-old male patient with hepatoportal bile duct cancer. A: USC after PTCD clearly tracks to the drainage duct alignment. A 60-year-old female with pancreatic cancer. B: After PTCD, USC can clearly show the low bile duct and part of the intestinal duct without interference from gastrointestinal gas.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6605022/v1/999f2133c8d4c59d864873de.png"},{"id":87365820,"identity":"3fe3c811-4659-4094-9b9a-6d56c5197da0","added_by":"auto","created_at":"2025-07-23 06:29:11","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":478896,"visible":true,"origin":"","legend":"\u003cp\u003eA 61-year-old male with hepatoportal bile duct cancer. The patient had abdominal pain and fever 2 d after D-CEUS-guided PTCD. A: US showed that the dilatation of intrahepatic bile ducts was not obvious after drainage, and the location of the end of the drainage ducts was not clearly explored; B: USC showed that the liver parenchyma and part of the intrahepatic bile ducts were visualized under palpation, and the lateral foramen of the drainage ducts was suspected to be partially prolapsed, and the ducts were transferred under cholangiography guidance; C: USC showed that the bilateral lobe bile ducts were clearly visualized after transfer. The patient was a 54-year-old female with cholangiocarcinoma of the porta hepatis and acute cholecystitis. 7 d after D-CEUS-guided PTCD the patient had poor drainage with high fever, chills and abdominal pain. D-E:USC began to inject contrast agent and the gallbladder was visualized, and part of the bile duct in the right lobe of the liver was visualized, followed by the liquid dark area next to the gallbladder, suggesting the possibility of bile leakage due to gallbladder perforation; F: US-guided perforation and aspiration.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-6605022/v1/c93dc239b255b1813bc94bb5.png"},{"id":87362778,"identity":"8425d27c-2d9f-4a2d-85ac-5d19085df4c9","added_by":"auto","created_at":"2025-07-23 05:57:11","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":47599,"visible":true,"origin":"","legend":"\u003cp\u003eFive cases of poor drainage tube drainage after PTCD and their corresponding characteristic patterns of cholangiography\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-6605022/v1/fc1b0818d2f10fc8c4c86be6.png"},{"id":88675323,"identity":"0fcc1b58-73f4-401a-be55-e68e265dd355","added_by":"auto","created_at":"2025-08-09 07:01:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2616369,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6605022/v1/34f299ce-87e7-4ba9-bf68-ca5ada3fdf7c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The clinical value of dual contrast-enhanced ultrasound in PTCD in patients with biliary obstruction","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBile duct placement and drainage is significant for palliative reduction of yellowness in patients with malignant biliary obstruction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], radical surgical treatment and improvement of liver function before radiotherapy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].Routine ultrasound-guided percutaneous transhepatic cholangial drainage (UG-PTCD) is favored by clinicians and patients because of its safety, convenience, and ability to be performed at the bedside in real time. However, there is a lack of scientific and perfect guidance evaluation system for bile duct placement and drainage, and the effect of yellowing reduction and drainage in some patients cannot be followed and adjusted for a long time.In this study, we retrospectively analyzed patients who underwent D-CEUS, in other words, CEUS and USC monitoring and modulation, to evaluate the value of D-CEUS in PTCD in patients with biliary obstruction in our hospital with ultrasound-guided biliary drainage.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatient information\u003c/h2\u003e\u003cp\u003eNineteen patients with surgical pathology or clinically confirmed diagnosis of hilar cholangiocarcinoma, one patient with intrahepatic cholangiocarcinoma, one patient with gallbladder cancer invading the liver parenchyma, and eight patients with pancreatic head cancer who underwent PTCD at the Ultrasound Medical Center of our hospital from October 2018 to January 2020.All patients were divided into two groups A and B. In group A, US-guided PTCD drainage and late monitoring were performed in 7 males and 7 females, aged 37 to 72 years, with a mean age of (60.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7) years, while in group B, D-CEUS-guided PTCD drainage and late monitoring were performed in 8 males and 7 females, aged 35 to 73 years, with a mean age of (60.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8) years.There was no statistical difference in the general condition of the patients before treatment between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05)(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).Inclusion criteria: patients who underwent UG-PTCD alone and patients who also underwent D-CEUS examination and evaluation with complete imaging and laboratory data. Exclusion criteria: patients with obstruction, occupying US that cannot be demonstrated, patients with obstructive jaundice operated by multiple biliary drainage modalities at the same time, and incomplete imaging and laboratory investigations.Finally 29 patients with obstructive jaundice with 34 drainage tubes were included in this study. The study was conducted in accordance with the principles of the Declaration of Helsinki,and the study protocol was approved by the ethics committee of Second Hospital of Lanzhou University.Because of the retrospective nature of the study,patient consent for inclusion was waived\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of the two groups of patients before drainage.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTBIL(umol/L)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eγ-GGT(U/L)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eALT(U/L)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e293.8\u0026thinsp;\u0026plusmn;\u0026thinsp;113.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e670.4\u0026thinsp;\u0026plusmn;\u0026thinsp;230.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e165.1\u0026thinsp;\u0026plusmn;\u0026thinsp;62.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e296.6\u0026thinsp;\u0026plusmn;\u0026thinsp;128.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e663.9\u0026thinsp;\u0026plusmn;\u0026thinsp;235.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e164.9\u0026thinsp;\u0026plusmn;\u0026thinsp;55.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eχ2/t\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c3\" namest=\"c2\" rowspan=\"2\"\u003e\u003cp\u003e0.032\u003c/p\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-0.243\u003c/p\u003e\u003cp\u003e0.809\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003cp\u003e0.954\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-0.072\u003c/p\u003e\u003cp\u003e0.943\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003cp\u003e0.993\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eApparatus and methods\u003c/h3\u003e\n\u003cp\u003eEPIQ 7 and LOGIQ E9 color Doppler ultrasound diagnostic instruments were applied, equipped with probes C5-1, X6-1, C6-1, and probe frequencies of 1\u0026ndash;5 MHZ, and cholangiography was performed using a specific low mechanical index contrast technique with mechanical index\u0026thinsp;\u0026le;\u0026thinsp;0.2. The ultrasound contrast agent is SonoVue (Bracco, Italy), which is diluted by adding 5 ml of 0.9% saline to each drug according to the instructions and shaken vigorously to form a suspension. There is no standard dose of intracorporeal contrast agent, which varies according to the type, size and location of the examined cavity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], according to a ratio of 1:200, i.e., every 0.1 ml of SonoVue suspension is added to 20 ml of warm saline for dilution. 20 ml of warm saline was diluted, and each dosage was 20\u0026ndash;100 ml, which was injected through the drainage tube,CEUS 2.4 ml of suspension was injected directly in the group along the elbow vein.\u003c/p\u003e\u003cp\u003eAll patients underwent routine ultrasound whole abdominal exploration to understand the shape of the lesion at the site of obstruction and its relationship with the bile duct wall and the degree of bile duct obstruction, as well as to observe the anatomical alignment of the biliary tree, the bile duct tortuosity, the extent and degree of dilatation, and to staging patients with cholangiocarcinoma of the hilar region according to the Bismush-Corlette staging [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePatients in group A underwent US assessment only before PTCD, while patients in group B underwent CEUS after routine ultrasonography, focusing on the mode of enhancement of the lesion, the relationship between the lesion and the biliary tract lumen and wall, and the degree of biliary obstruction.\u003c/p\u003e\u003cp\u003eIn patients without any biliary drainage operation, PTCD was performed under US guidance in group A. In group B, ultrasound-guided PTCD was performed after CEUS, and if necessary, PTCD was performed under D-CEUS guidance, and the operation images were retained to decide the placement method with reference to the dilated course of the confluent bile duct of the obstructed lumen and its relationship with the common bile duct and the degree of biliary obstruction. In patients with biliary lumen occupancy, the nature of the biliary lumen occupancy and its relationship with the bile duct wall were also one of the considerations in deciding the placement method.\u003c/p\u003e\u003cp\u003ePatients in group B after PTCD operation were first decompressed by slowly withdrawing an appropriate amount of bile through the drainage tube under conventional ultrasound surveillance (20\u0026ndash;100 ml was routinely withdrawn) and measured. The patient was then asked to hold his breath and slowly injected along the drainage tube in ultrasonography mode, and a more complete view of the biliary tree and the obstruction site was selected (usually the right side of the subxiphoid process or the right intercostal probe facing the hepatoportal area) for video recording.\u003c/p\u003e\u003cp\u003ePatients with poor drainage in group A underwent US review assessment, also every two days.\u003c/p\u003e\u003cp\u003eThe patients' clinical symptoms, drainage fluid properties and values of total bilirubin, drainage bile volume, γ-glutamyl transferase (γ-GT) and glutathione aminotransferase (ALT) 1 day before and 1 day, 3 days and 7 days after drainage were recorded daily after the operation.\u003c/p\u003e\n\u003ch3\u003eStatistical method\u003c/h3\u003e\n\u003cp\u003eSPSS 25.0 statistical software was used, and the chi-square test or Fisher's exact probability method was used for counting data, and (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s) was used for measurement data, in which bile drainage, total bilirubin, γ-GT, and ALT were analyzed by one-way ANOVA with repeated measurements, and differences were considered statistically significant at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Using R4.1.1 to make group scatter plots of total bilirubin, γ-GT, ALT and bile drainage after PTCD.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eThe bile drainage in group B was higher than that in group A, and the difference was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The serum total bilirubin, γ-GT and ALT levels were lower than those in group A, and the difference was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05)(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe drainage and liver biochemical indicators of the two groups of patients.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelated indicators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDetection time\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDrained bile volume(ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e312.9\u0026thinsp;\u0026plusmn;\u0026thinsp;46.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e424.3\u0026thinsp;\u0026plusmn;\u0026thinsp;128.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.085\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e278.1\u0026thinsp;\u0026plusmn;\u0026thinsp;49.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e426.4\u0026thinsp;\u0026plusmn;\u0026thinsp;94.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e242.4\u0026thinsp;\u0026plusmn;\u0026thinsp;42.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e464.3\u0026thinsp;\u0026plusmn;\u0026thinsp;97.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eTBIL(umol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e236.7\u0026thinsp;\u0026plusmn;\u0026thinsp;125.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e192.4\u0026thinsp;\u0026plusmn;\u0026thinsp;99.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.154\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e202.0\u0026thinsp;\u0026plusmn;\u0026thinsp;125.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e133.4\u0026thinsp;\u0026plusmn;\u0026thinsp;85.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e168.5\u0026thinsp;\u0026plusmn;\u0026thinsp;121.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e92.3\u0026thinsp;\u0026plusmn;\u0026thinsp;79.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eγ-GT(U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e595.1\u0026thinsp;\u0026plusmn;\u0026thinsp;239.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e518.7\u0026thinsp;\u0026plusmn;\u0026thinsp;224.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e429.7\u0026thinsp;\u0026plusmn;\u0026thinsp;258.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e301.5\u0026thinsp;\u0026plusmn;\u0026thinsp;191.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e253.6\u0026thinsp;\u0026plusmn;\u0026thinsp;233.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e164.5\u0026thinsp;\u0026plusmn;\u0026thinsp;148.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eALT(U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e159.4\u0026thinsp;\u0026plusmn;\u0026thinsp;61.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e128.7\u0026thinsp;\u0026plusmn;\u0026thinsp;54.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.603\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e125.0\u0026thinsp;\u0026plusmn;\u0026thinsp;55.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.8\u0026thinsp;\u0026plusmn;\u0026thinsp;36.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDay 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90.8\u0026thinsp;\u0026plusmn;\u0026thinsp;44.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41.3\u0026thinsp;\u0026plusmn;\u0026thinsp;20.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the group of 14 patients, preoperatively, US found one case of complete obstruction of the secondary bile duct, three cases of complete obstruction of the primary bile duct, two cases of incomplete obstruction, five cases of complete obstruction of the extrahepatic bile duct, and three cases of incomplete obstruction. Among them, there were 3 cases of left and right lobe obstruction, 1 case was successfully given bilateral catheterization, and the other 2 cases were only catheterized on the opposite side due to the failure of one bile duct puncture (1 case had no bile duct dilatation 2 days after operation, which proved that the left and right lobes were connected, and no additional Catheterization, another case found bile duct dilatation 2d after operation, and catheterization was repeated).The left and right lobes were connected in 11 cases, and 4 cases were unable to deliver the guide wire to the obstructive segment because of multiple small partitions in the selected target bile duct.In group A, there were 5 patients (5/14 (35.71%)) with failed catheter placement and poor placement of the catheter, and 15 patients in group B had successful catheter placement at one time (15/15 (100%)). The difference between groups was statistically significant (\u003cem\u003eχ2\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8.413, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).In group B, one case of complete obstruction of tertiary bile ducts, 3 cases of complete obstruction of primary bile ducts, 10 cases of complete obstruction of extrahepatic bile ducts and one case of incomplete obstruction were found in preoperative US.One case of incomplete obstruction of tertiary bile ducts, 2 cases of incomplete obstruction of primary bile ducts, one case of complete obstruction, 5 cases of complete obstruction of extrahepatic bile ducts, and 6 cases of incomplete obstruction were confirmed by D-CEUS.In one patient, preoperative conventional ultrasound thought that the target bile duct was completely obstructed, and the distance from the puncture point to the obstruction site was too small, and the drainage range was limited, so it was considered unsuitable for PTCD drainage.On the other hand, CEUS and USC both showed incomplete obstruction. The drainage tube was successfully placed, and the postoperative drainage was smooth.(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).Both the left and right lobe bile ducts were found to be blocked by conventional ultrasound in 2 patients, and bilateral catheters were required. After catheter placement, USC assessment showed that both left and right lobe bile ducts were visualized, and no additional catheter placement was required (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).Only one case of USC evaluation also required bilateral placement of drains, and 11 cases with left and right lobe communication were successfully delivered to the extrahepatic bile duct under real-time USC guidance (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), with postoperative USC suggesting total hepatic drainage.\u003c/p\u003e\u003cp\u003eAmong the patients in Group A, one patient developed transient bloody bile after PTCD due to a misjudgment of the extent of tumor invasion of the bile ducts, suspicion of touching the tumor in the duct lumen during puncture, and in one patient, bile leakage complication occurred due to the target bile duct being too thin and the head end of the drainage tube could not be monitored accurately and in real time, and the drainage tube was later successfully placed via US-guided transfer several times.One patient showed periductal ooze 4 d after surgery, suspected to be drainage tube blockage, and the drainage condition was acceptable after flushing. 3 patients had postoperative abdominal pain with reduced drainage, and the dilatation of the intrahepatic bile duct was reduced on US exploration, and the drainage tube was in place, so anti-inflammatory and analgesic symptomatic treatment was given, and the symptoms were slightly relieved.One patient in group B developed acute symptoms such as chills, high fever, and severe abdominal pain 1 week after drainage due to acute cholecystitis. The perforation of acute cholecystitis was confirmed by USC, and ultrasound-guided puncture and fluid extraction were performed in one patient. Two days after the operation, the drainage volume suddenly decreased, accompanied by abdominal pain, which continued to aggravate. It was confirmed by USC that the side hole of the drainage tube was partially prolapsed (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). There was a statistically significant difference in postoperative complications between groups A and B (\u003cem\u003eχ2\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.585, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of complications and differences in drainage volume after drainage between the two groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePostoperative bloody bile\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePostoperative bile leak\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePostoperative peritubular exudate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eabdominal pain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003etotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(7.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(7.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1(7.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3(21.43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6(42.86)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1(6.67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1(6.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eχ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003e5.585\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHilar cholangiocarcinoma is usually found in the middle or late stage due to the special anatomical location, the chaotic and complex surrounding vascular structure, and the lack of obvious clinical symptoms.Surgery is the only possible way to cure hilar cholangiocarcinoma, but the surgical conditions are demanding. If multiple bile ducts and blood vessels in the liver are invaded, it will be inoperable, and PTCD plays an important role in both preoperative yellowing reduction and palliative hepatoprotective drainage treatment.Tang et al [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] concluded by meta-analysis that especially in patients with Bismush-Corlette type II, III or IV, PTCD should be used as an initial method of biliary drainage in order to reduce the incidence of surgery-related cholangitis, pancreatitis and to improve the palliative palliative treatment aspect of cholestasis.However, there is a lack of accurate and effective preoperative placement decision evaluation system for PTCD; there is a lack of complete postoperative drainage follow-up evaluation system, which is detrimental to the improvement of patient survival quality and better preoperative yellowing reduction and postoperative protection of residual liver function.\u003c/p\u003e\u003cp\u003eIn this study, we found that the overall bile drainage in group A was lower than that in group B on days 1, 3 and 7 after biliary drainage, and there was a significant difference between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).Total bilirubin, γ-GT and ALT in group A were generally higher than those in group B. There was a significant difference between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).The main reason for the lower drainage in group A than in group B may be that the end of the drainage tube was not placed at the optimal drainage point.In order to obtain the best drainage, the drainage tube must be located downstream of the confluence of multiple unobstructed bile duct tributaries, so as to achieve the effect of \"all rivers in the sea\".Wang et al [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported that the drainage flow was closely related to the cross-sectional area of the drainage duct, length, length and location of the drainage duct in the bile duct, and with low obstruction, the lateral hole of the drainage duct was located in the common bile duct than in the left and right hepatic ducts. Preoperative CEUS for PTCD enables accurate Bismush-Corlette typing of the porta hepatis, the degree of biliary obstruction, the identification of biliary mud deposits in the bile ducts from other occupancies, and the relationship between the extent of both and the bile duct wall to better guide the selection of target bile ducts for punctal drainage. Intraoperative real-time biliary ultrasonography guidance also allowed for a more visual observation of the draining bile ducts, which explains why all 15 patients in group B were successfully placed in one visit (15/15 (100%)) and the difference in placement success rate between groups A and B was statistically significant (\u003cem\u003eχ2\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8.413, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).Conventional ultrasound often cannot track the catheter in real time and requires high operator skill and experience, while the accuracy of percutaneous transhepatic cholangiography (PTC) in determining the cause of obstruction has been reported in the literature to be only 63%, USC improves the visualization of the catheter tip and can accurately define the level of biliary obstruction up to 100% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].USC is well suited to observe the fifth-order branches of the biliary tree and is therefore considered as an alternative to radiological PTC [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].Chandra et al [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] concluded that intraoperative ultrasound using saline as a contrast agent is significant for biliary surgery as an inexpensive and concise navigation modality that can accurately visualize isolated small bile ducts in the liver.After PTCD, the bile duct is significantly less dilated or even non-dilated, and it is difficult for US to determine the location and status of the end of the drain due to the lack of a hypoechoic acoustic window; however, USC improves visualization of the biliary system, especially in the undilated bile duct system [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].USC allows for clearer observation of the drainage tube alignment, the presence or absence of folding at the end, the number of draining branch bile ducts, and the extent of the liver lobe covered, providing real-time guidance for duct adjustment (Figs.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).Similarly, USC was found to be able to accurately show the drain alignment and end position with better results than US, and to assess the extent of drainage and reduce the incidence of complications such as poor drainage and bile leakage after PTCD [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].Total bilirubin, gamma-glutamyl transferase, and glutamyl transaminase were generally higher in group A than in group B after drainage probably because of the following deficiencies in US compared to D-CEUS: 1. The extent of drainage cannot be judged, and often only a few branches or 1 branch of the left or right lobe is drained, which does not improve the overall liver function.2. After the position of the lateral orifice of the drainage tube is removed from the optimal drainage site, although the drainage flow may remain temporarily unchanged, the segment of the liver that actually needs drainage most to improve liver function fails to receive advantageous drainage.3. D-CEUS allows regular inspection and identification of bile sludge deposited in the bile duct, which is more acute and reliable than direct visual observation of the viscosity and other properties of the drained bile to determine the time of flushing.It has been reported that CEUS can help differentiate benign and malignant causes of obstructive jaundice, improve the detection of bile duct infiltration in liver tumors, and allow better assessment of the internal blood supply and extension of hilar hepatobiliary tumors [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].The incidence of complications after PTCD in group A was significantly higher than that in group B, and there was a significant statistical difference between the two groups (\u003cem\u003eχ2\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.585, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), which may be due to the following points:D-CEUS can evaluate the nature of the lesions in the obstructed bile duct before operation, detect the position of the puncture needle tip and the position of the drainage tube after the catheter placement, avoid touching the accompanying blood vessels around the bile duct, and the rich blood supply tumor in the bile duct to cause hemorrhage or bloody bile, reduce the incidence of bile leakage caused by puncture needle and drainage tube breaking through the anterior and posterior walls of the bile duct or exiting into the liver parenchyma.In addition to PTCD, the use of USC during thermal ablation of tumors was found to protect the bile ducts [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and similarly, CEUS can provide valuable information for surgical decision making during surgery for hepatoportal cholangiocarcinoma [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCEUS is valuable for preoperative assessment, placement decision and postoperative transfer of PTCD, which reduces postoperative complications of PTCD and improves the success rate to some extent.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflicts of Interest\u003c/h2\u003e\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInstitutional Review Board Statement\u003c/b\u003e: This is a retrospective study that complies with the Declaration of Helsinki and does not require ethical review.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInformed Consent Statement\u003c/b\u003e: Not applicable.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConflicts of Interest\u003c/b\u003e: The author declare no conflict of interest.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLongli Wang completed the data collection and statistical analysis, and finally wrote this article\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMa J, Luo J, Gu J, et al. Malignant obstructive jaundice treated with intraluminal placement of Iodine-125 seed strands and metal stents: An analysis of long-term outcomes and prognostic features. Brachytherapy 2018;17(4): 689\u0026ndash;695.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoole H, Bechtold M, Puli S R. Efficacy of preoperative biliary drainage in malignant obstructive jaundice: a meta-analysis and systematic review. World J Surg Oncol 2016;14(1): 182.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKljučevšek D, Riccabona M, Ording M\u0026uuml;ller LS, et al. Intracavitary contrast-enhanced ultrasonography in children: review with procedural recommendations and clinical applications from the European Society of Paediatric Radiology abdominal imaging task force. Pediatr Radiol 2020;50(4):596\u0026ndash;606.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIgnee A, Cui X, Schuessler G, Dietrich CF. Percutaneous transhepatic cholangiography and drainage using extravascular contrast enhanced ultrasound. Z Gastroenterol 2015;53(5):385\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg 1992;215(1): 31\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTang Z, Yang Y, Meng W, et al. Best option for preoperative biliary drainage in Klatskin tumor: A systematic review and meta-analysis. Medicine (Baltimore) 2017;96(43): e8372.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang C, Liu J W, Wang Z M, et al. Application of percutaneous transhepatic cholangial drainage in the treatment of bile duct obstruction with malignant hilar bile duct carcinoma. Journal of Regional Anatomy and Operative Surgery 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLuyao Z, Xiaoyan X, Huixiong X, et al. Percutaneous ultrasound-guided cholangiography using microbubbles to evaluate the dilated biliary tract: initial experience. Eur Radiol 2012;22(2):371\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSp\u0026acirc;rchez Z, Radu P. Role of contrast enhanced ultrasound in the assessment of biliary duct disease. Med Ultrason 2014;16(1):41\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoberts JP, Neill A, Goldstein R. The use of a micro-bubble contrast agent to allow visualization of the biliary tree. Clin Transplant 2006;20(6):740\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChandra A, Gupta V, Rahul R, et al. Intraoperative ultrasonography of the biliary tract using saline as a contrast agent: a fast and accurate technique to identify complex biliary anatomy. Can J Surg 2017; 60(5): 316\u0026ndash;322.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang DY, Yusuf GT, Daneshi M, et al. Contrast-enhanced ultrasound (CEUS) in abdominal intervention. Abdom Radiol (NY) 2018;43(4):960\u0026ndash;976.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eComo G, Montaldo L, Baccarani U, et al. Contrast-enhanced ultrasound applications in liver transplant imaging. Abdom Radiol (NY) 2021;46(1):84\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMao R, Xu EJ, Li K, Zheng RQ. Usefulness of contrast-enhanced ultrasound in the diagnosis of biliary leakage following T-tube removal. J Clin Ultrasound 2010;38(1):38\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFontan F J, Reboredo A R, Siso A R. Accuracy of Contrast-Enhanced Ultrasound in the Diagnosis of Bile Duct Obstruction. Ultrasound Int Open 2015;1(1): E12-8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMM Yating Su, You Y, MM Qingjing Zeng, et al. Transcholecystic Contrast-Enhanced Ultrasound-Guided Percutaneous Transhepatic Biliary Drainage for Central Bile Duct Protection During Thermal Tumor Ablation - ScienceDirect. Journal of Vascular and Interventional Radiology 2020;31(10):1587\u0026ndash;1591.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWerner JM, Zidek M, Kammerer S, da Silva NPB, Jung F, Schlitt HJ, Hornung M, Jung EM. Intraoperative contrast-enhanced ultrasound can have a crucial role in surgical decision-making during hepato-pancreatico-biliary surgery - Analysis of impact and input. Clin Hemorheol Microcirc 2021;78(1):103\u0026ndash;116.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Percutaneous transhepatic cholangial drainage, Dual contrast enhanced ultrasound, Biliary obstruction, Ultrasonic cholangiography, Contrast enhanced ultrasound","lastPublishedDoi":"10.21203/rs.3.rs-6605022/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6605022/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo evaluate the clinical value of double contrast enhanced ultrasound (D-CEUS) in percutaneous transhepatic cholangial drainage (PTCD) in patients with biliary obstruction.Try to evaluate the clinical significance of double contrast enhanced ultrasound (D-CEUS) in catheterization and drainage of patients with biliary obstruction .\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e29 patients with biliary obstruction underwent catheterization and drainage under the guidance of conventional ultrasound (US). Among them, 15 patients underwent double contrast enhanced ultrasound (D-CEUS), which includes transvenous contrast enhanced ultrasound (CEUS) and ultrasonic cholangiography (USC), were set as group B (experimental group), postoperative drainage and poor yellow reduction were guided by double contrast enhanced ultrasound (D-CEUS); the remaining 14 patients were were randomized as control (group A) without other operations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe bile drainage volume of patients in group A was lower than that of group B at 1, 3, and 7 days after receiving biliary drainage, and the difference between the two groups was statistically significant (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16.085, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The total bilirubin, γ-GT, and ALT in group A were higher than those in group B, and the difference between the two groups was statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There were 5 patients in group A who failed to insert the tube and the position of the tube was poor (5/14 (35.71%)), and all 15 patients in group B were successful in one-time catheterization (15/15 (100%)), and the difference between the two groups was statistically significant (\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;8.413, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). Six patients in group A had postoperative complications, and there was only one patient in group B, and the difference between the two groups was statistically significant (\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;5.585, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003edouble contrast enhanced ultrasound (D-CEUS) can effectively perform preoperative lesion assessment, intraoperative catheter placement navigation, and postoperative auxiliary adjustment for biliary obstruction patients undergoing percutaneous transhepatic cholangial drainage (PTCD), which effectively improving the efficiency of reducing yellowing.\u003c/p\u003e","manuscriptTitle":"The clinical value of dual contrast-enhanced ultrasound in PTCD in patients with biliary obstruction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 05:57:06","doi":"10.21203/rs.3.rs-6605022/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b1ac6e34-d87c-4dcb-9f8f-52fed0b53d38","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-09T06:53:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-23 05:57:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6605022","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6605022","identity":"rs-6605022","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}