Percutaneous Transhepatic Cholangiography and Biliary Drainage

Percutaneous transhepatic cholangiography (PTC) is the direct opacification of the intrahepatic and extrahepatic bile ducts by injecting contrast through a thin needle (21 to 22 gauge, the Chiba needle) passed through the skin and liver into a peripheral bile duct, under ultrasound and fluoroscopic control. It defines the level and cause of biliary obstruction, bile leaks and strictures.

When obstruction or sepsis is present, the study is converted to percutaneous transhepatic biliary drainage (PTBD). A wire is passed through the obstruction, and a drainage catheter is placed.

• External drainage: the tip lies proximal to the obstruction.
• Internal external drainage: side holes lie on each side of the obstruction, so bile drains into the duodenum and externally.

Further steps include stenting of malignant strictures with self-expanding metal stents, balloon dilatation of benign strictures, stone removal, and biopsy of the stricture. Left or right duct approaches are chosen from the imaging: the left (subxiphoid) approach is easier in fasting patients and is more comfortable, and the right (lateral intercostal) approach reaches the right system.

Obstructive jaundice is a common surgical and medical problem. Malignant obstruction (cholangiocarcinoma, pancreatic head cancer, gallbladder cancer, nodal metastases) accounts for the majority of cases needing drainage, and benign causes include stones, strictures after surgery or inflammation, and sclerosing cholangitis.

Endoscopic retrograde cholangiopancreatography is the first route for most distal obstruction, and percutaneous drainage is used when the endoscopic route fails or is not possible (hilar obstruction, altered anatomy after gastric bypass or hepaticojejunostomy, duodenal obstruction, failed cannulation, bile duct leak).

MR cholangiopancreatography now provides diagnostic imaging without needles, so PTC is mostly the first step of a therapeutic procedure.

Indications.

• Malignant biliary obstruction (hilar and high bile duct) for palliative drainage and stenting, or pre-operative drainage when indicated (cholangitis, severe jaundice with renal impairment, delayed surgery, or before chemotherapy).
• Acute obstructive cholangitis when endoscopic drainage has failed or is not possible.
• Failed or unsuitable endoscopic retrograde cholangiopancreatography: anatomical alteration, duodenal stricture or tumour, failed cannulation.
• Bile leak after surgery or trauma (external drainage diverts bile).
• Benign biliary strictures (post-operative, anastomotic, inflammatory) for dilatation and stenting.
• Intrahepatic or common duct stones that cannot be removed endoscopically.
• Access for biopsy, brushings, photodynamic treatment, or brachytherapy of cholangiocarcinoma.
• Biliary diversion before major hepatic surgery or radiotherapy.
• Diagnostic PTC when MR cholangiopancreatography and endoscopic tests are inconclusive (rare).
• Not for unilateral drainage of an atrophied segment without cholangitis, and not for jaundice from hepatocellular disease.

Contraindications.

• Uncorrectable coagulopathy (international normalised ratio over about 1.5 and platelets under 50 000 in each microlitre, as the local rule sets).
• Severe ascites that cannot be drained.
• No safe access route (undilated ducts in a small liver make the procedure difficult).
• A patient who cannot lie still.

Relative: contrast allergy, severe sepsis (drain and give antibiotics, proceed gently), hydatid disease (a risk of spillage and anaphylaxis), and extensive hepatic metastases limiting a safe path. Obstruction caused by a hydatid cyst needs specialist planning.

Preparation.

• Informed consent, with benefits, alternatives (endoscopic drainage, surgery) and risks explained.
• Review of cross-sectional imaging (CT or MR cholangiopancreatography) to map the ducts, to decide which segments to drain, and to avoid draining isolated, non-communicating segments.
• Blood tests: full blood count, clotting, renal function, liver function, and group and screen; correction of coagulopathy (vitamin K for cholestasis, plasma or platelets if needed).
• Intravenous broad spectrum antibiotics, started before the procedure (covering enteric Gram negative organisms and anaerobes), continued if infection is present.
• Fasting for 6 hours, hydration (obstructive jaundice carries a risk of acute kidney injury), analgesia and sedation, monitoring, and vigilant management of septic shock risk.

Technique. The skin is cleaned and local anaesthetic is given down to the liver capsule. Under ultrasound, a peripheral duct is selected, and the fine needle is advanced under fluoroscopy while contrast is injected; gentle injection (avoid overdistension, which provokes bacteraemia) outlines the biliary tree.

Once a suitable duct is found, a wire is passed, the tract is dilated, and a sheath and drainage catheter (8 to 12 French) are placed. The obstruction is crossed with a hydrophilic wire and catheter, a cholangiogram is done distal to the lesion, and an internal external drain is positioned.

For malignant obstruction, a self-expanding metal stent may be deployed at the same time or after a few days, once the sepsis has settled. The drain is secured and connected to a bag. Samples of bile are sent for culture.

Findings.

• Normal ducts: intrahepatic ducts of 1 to 3 mm in calibre branching smoothly, with a common hepatic duct of up to 6 mm.
• The common bile duct is up to 6 to 8 mm (up to 10 mm after cholecystectomy), with a smooth, tapering ampulla and free flow of contrast into the duodenum.
• Level of obstruction: hilar (confluence of the right and left hepatic ducts, classified by extent of involvement of the secondary ducts), mid common duct, or distal (pancreatic head).
• Malignant stricture: a shouldered, irregular, abrupt or "apple core" narrowing with proximal dilatation.
• Hilar cholangiocarcinoma shows a stricture at the confluence with separation of the right and left systems.
• Pancreatic cancer shows a smooth tapering stricture of the distal duct ("double duct sign" when the pancreatic duct is also dilated).
• Benign stricture: a short, smooth, concentric narrowing (post-operative or inflammatory), with a tapered ("rat tail") outline, and in primary sclerosing cholangitis, multifocal strictures and dilatations ("beaded" ducts) with a "pruned tree" appearance.
• Stones: round or faceted filling defects, often multiple, with dilated ducts, and a meniscus sign at the lower end.
• Bile leak: extravasation of contrast outside the ducts, often from the cystic duct stump, the duct of Luschka, the anastomosis, or an injured duct.
• Congenital anomalies: choledochal cysts (fusiform or cystic dilatation of the common duct), Caroli disease (saccular dilatation of intrahepatic ducts), and aberrant ducts (right posterior duct draining into the left system).
• Parasitic: Ascaris or liver flukes as linear filling defects, and hydatid cyst communication with debris and membranes in the ducts.
• Cholangitis: cloudy, turbid bile, debris, pus in the ducts, and dilated ducts.
• Post-operative: anastomotic strictures after hepaticojejunostomy or liver transplantation, ischaemic strictures, and clips across the duct.
• Response after drainage: falling bilirubin (expected fall of about 50% in 1 to 2 weeks), resolution of cholangitis, and decompressed ducts.

Critical findings needing immediate action. Cholangitis or septic shock with an obstructed system (urgent drainage, intravenous antibiotics, fluids and vasopressors), haemobilia or haemorrhage (hypotension, blood in the drain: angiography and embolisation of a hepatic artery injury), bile peritonitis or bile leak into the peritoneum,

pneumothorax or haemothorax from a transpleural puncture, drain dislodgement with leakage, a new bile leak, anaphylaxis, and acute kidney injury (hepatorenal syndrome).

Complications.

• Sepsis and bacteraemia (up to 5 to 10% of cases and the main cause of death, higher with cholangitis).
• Bile leak and biliary peritonitis (up to 5%).
• Haemorrhage (haemobilia, haemoperitoneum, subcapsular haematoma, hepatic artery pseudoaneurysm: 2 to 3% need intervention).
• Pneumothorax, pleural effusion or bilothorax (with a right intercostal approach).
• Catheter blockage and dislodgement (common: 20 to 30% need exchange within 3 months).
• Stent occlusion (by tumour ingrowth or sludge: median patency of 4 to 8 months for uncovered metal stents).
• Cholecystitis, pancreatitis, portal vein injury, and pain.

Technical success is 95% in dilated ducts and 70 to 80% in non-dilated ducts. Procedure related mortality is about 1 to 2%.

Aftercare.

• Bed rest for 4 to 6 hours (lying on the side of the puncture where possible), with observation of pulse, blood pressure, temperature, pain and drain output every 15 to 30 minutes at first.
• Continue antibiotics for 24 to 72 hours, or longer if cholangitis, and monitor for fever, rigors and hypotension.
• The external drain is connected to a bag at first; output of 500 to 1000 mL each day is common, replaced with fluids and electrolytes if high. The tube is flushed with 10 mL of saline every 12 to 24 hours to prevent sludge blocking.
• Exchange of the catheter every 2 to 3 months (or earlier if blocked), unless a metal stent is placed.
• Monitor bilirubin, liver function, and renal function, and repeat imaging for persistent jaundice or blockage.
• Return for fever, rigors, jaundice, pain, bile leakage around the tube, drain falling out or output stopping, or bleeding.

Special groups.

• Children: rare (biliary atresia and post-transplant strictures) at specialist centres under general anaesthesia.
• Elderly and frail: palliative drainage with stents improves symptoms (itching, cholangitis) with limited prognosis.
• Patients with liver transplant: anastomotic and ischaemic strictures treated with dilatation and stenting.
• Pregnancy: ultrasound control; avoid fluoroscopy where possible.
• Ascites: drain before the procedure to reduce leak and bleeding.
• Regions: parasitic and stone disease (recurrent pyogenic cholangitis, hepatolithiasis, ascariasis, liver flukes, hydatid disease) and late presentation with hilar cholangiocarcinoma and pancreatic cancer are common; PTC is often the only available route for biliary decompression.