This document describes percutaneous transhepatic biliary drainage (PTBD) and biliary stenting procedures. PTBD is performed when endoscopic retrograde cholangiopancreatography (ERCP) is not possible to relieve biliary obstruction. It involves puncturing the bile duct under imaging guidance and placing a catheter to drain bile externally or internally. Biliary stenting can then be done to open the blockage long-term by inserting a plastic or metal stent over a wire. PTBD provides minimally invasive relief of obstruction and preserves liver function when surgery is not an option. Risks are generally low but include bleeding, infection, and injury to nearby structures.

1. Dr. AKM Anowar Hossain Mukul
MBBS, MD
Interventional Radiologist
Bangabandhu Sheikh Mujib Medical University
( BSMMU ), Dhaka
Percutaneous Transhepatic Biliary Drainage
( PTBD ) & Stenting – when ERCP is not
possible

2. Fig-CT scan of GB mass with portahepatis invasion with biliary obstruction

3. Fig-Portal infiltration of cholangiocarcinoma. A: Axial CT in the portal phase shows
a periductal mass in the portal confluence (arrowheads) producing biliary dilatation
(arrows); B: The mass extends cranially and shows encasement and infiltration of
the left portal vein.

4. Fig- MRCP of Hilar cholangiocarcinoma

5. Fig- PTBD ( internalization) Fig- Biliary stenting

6.  Procedure in which the bile duct is punctured through skin and liver
by a needle under ultrasound & fluoroscopic guidance.
 Wire is placed followed by catheter.
 This procedure is done under local anesthesia & mild sedation.
 Effective treatment for patients in whom ERCP is unsuccessful
or not possible.

7. Biliary externalization: In cases where wire can’t go beyond
obstruction or patients with active infection
Biliary internalization: Bile is to be drained within only; no external
bag. For malignancy metallic stent is placed.
Fig- A & B-External Fig C-Internal

8. Malignant obstruction
 Cholangiocarcinoma – specially Hilar.
 Ca-GB, Ca-stomach, duodenum with invasion into the biliary trees resulting
obstructive jaundice.
 Ampullary and pancreatic malignancies when retrograde access via ERCP is not
amenable
Benign obstruction
 Iatrogenic strictures- suture granuloma, diathermy burns, hemostasis clips,
amputation neuroma of the cystic duct
 Previous anastomosis (e.g. Post liver transplant)
Primary sclerosing cholangitis
Post-surgery bile leak in the site of the bilio-digestive anastomosis - PTBD
is performed in patients with non or minimally dilated bile ducts.

9.  Advanced cirrhosis.
 Coagulopathy.
 Moderate to massive ascites.

10.  Needs prior appointment.
 Lab investigations (APTT, PT/INR, CBC, LFTs, Viral markers etc).
 Blood thinner like Aspirin to be stopped, 3-5 days before the procedure.
 4-6 Hours fasting.
 Patient need to arrive early at the hospital with at least one accompanying person
for registration, admission, to sign a consent form and other administrative works.

11.  USG machine.
 Fluoroscopy unit.
 Puncture needle.
 Guide wires.
 Dilators.
 Catheters.
 Suture materials.
 Drainage bag.

12. Fig-Fine needle, access wire, vascular sheath, hydrophilic guide wire

13. Fig-RDC catheter, dilators, external drainage & internal drainage catheters.

14.  Performed in the Radiology Department by an Interventional Radiologist.
 Under conscious sedation, provided by an anesthesiologist, who, in addition to
sedation, will also monitor patient’s vital signs and breathing.
 Under sterile conditions, local anesthetic drug is injected into the skin, subcutaneous
tissue & liver capsule.
 A fine needle ( 20 / 18 G ) is inserted under ultrasound and fluoroscopic guidance
into the bile ducts.
 Then access guide wire & vascular sheath is inserted into the duct system.
 Contrast agent is injected to confirm successful entry into the duct system as
well as for mapping.

15.  Guide wires and catheters are then manipulated under fluoroscopic guidance to
cross the obstruction & to enter the duodenum.
 A biliary drainage catheter is then inserted over this wire, upto the 3rd part of the
duodenum ( internalization ).
 If there is failure to cross the obstruction – then externalization is done.
 Contrast agent is injected to confirm spontaneous drainage from the duct system to
the duodenum.
 Secure the catheter to the skin at the puncture site.
 Connect to a drainage bag to collect the bile- incase of externalization.

16. Fig- Cholangiogram through vascular sheath Fig- Hydrophic gidewire with RDC catheter

17. Fig-RDC catheter with hydrophilic gidewire Fig- drainage catheter over exchange gidewire

18. Fig- Final step of internalization

19.  Usual time of stay is around 1-2 Days.
 Monitoring in the recovery area of the Radiology Department, then transferred to
ward.
 Care of the Biliary drainage catheter- the catheter should be flushed daily with sterile
saline.
 Skin around the catheter should be clean & dry.
 Patient can take showers but the area should be covered with a plastic wrap.
 The drainage bag should be emptied regularly.
 The catheter should be changed every 2-3 months.
 How long PTBD is required and what is the next step- will be determined by referring
doctor depending on the cause.

20. BENEFITS
 When surgery or endoscopic relief is not possible , then a PTBD is the only means
of relieving the obstruction.
 Minimally invasive procedure.
 No general anesthesia.
 Infection and pain from the obstruction is relieved and the liver function is preserved.
RISKS
Overall, the risks are low-
 Bleeding at the puncture site or internal bleeding- usually self limiting.
 A small risk of infection.
 Pancreatitis .
 Inadvertent puncture of neighboring structures -pleura, lung (pneumothorax or
hematothorax ).
 Fistulae between the bile duct and hepatic artery or portal vein, pseudo aneurysm,
bile leaks.
 Contrast allergy.

21.  In some cases, if the blockage is long term or permanent drainage is required, there
may be an option to insert an internal plastic or metal tube to open up the blockage.
This is called a stent.
 Procedure is as same as PTBD ( internalization ).
 Long exchange guide wire ( about 300 cm ) is required.
 Stent is inserted instead of drainage catheter.
 This may be inserted at the time of PTBD procedure or after 1-2 months of PTBD
( internalization ) when mature tract is formed.
 If this can be successfully performed, the drainage catheter and bag can be
removed.

22. Fig- Zilver Biliary stent
Fig- Long exchange guide wire

23. Fig- Biliary stenting procedure

24. Fig- Sonographic evaluation of the stent