This presentation include biliary anatomy ,indication, contraindication post op care of percutaneus transhepatic biliary drainage with important technique. and advantage and disadvantage of different technique. This is important for radiologist, radiographers, intervention radiologist radiology resident. Thanks

1. PTCD/PTBD
Pradeep Kumar
Radiology resident

2. PTCD/PTBD
• Percutaneous Transhepatic biliary drainage is a therapeutic procedure
that involves sterile cannulation of periphery biliary radicle after
percutaneous puncture followed by imaging guide wires and catheter
manipulation.
•Placement of External
or Internal Stent or
drainage tube completes
the procedure

3. Biliary Tree Anatomy

6. www.ijri.org/articles/2016/26/1

9. Methods of Imaging Biliary Tract
• ➢Indirect Imaging
• Involves Non Invasive
Technique
1. Ultrasound
2. Plain Film
3. CT
4. MRCP
5. Oral, IV Cholecystography
6. Cholescintigraphy
➢Direct Imaging
Involves Invasive Radiologic Procedure
1. ERCP
2. Operative and T tube Cholangiogram
3. PTC

11. ERCP
PTC
T-TUBE CHOLANGIOGRAM

13. Contraindication
• Coagulation Problem ( Platelet count< 100,000 mm3 and INR greater
than 1.5 .
• Biliary Infection.
• Hypersensitivity to contrast medium
• Severe heart disease and respiratory disease
• Poor General condition of patient
• Extreme Jaundice.
• Ascites.
• Anemic
• Immediately after an hydatid cyst removal .
• Hydatid disease.
• Uncooperative patient.

14. Patient Preparation
• BLOOD TEST: Hemoglobin, Bilirubin, Sugar, Cholesterol, Haemogram,
Prothrombin time & Platelets, HBsAg, HCV, HIV test, Blood grouping
report.
• USG/CT/MRI report (information about level of obstruction &
assessment of the tumor resectability & planning appropriate
approach to biliary decompression).
• ECG, CXR report.

15. • Prophylactic antibiotics: Broad spectrum antibiotics from 24 hours
before procedure & for 3 days afterwards.
• NPO for at least 4-6 hours before procedure.
• Sedation/Analgesics : as required.
• Open IV line in a arm to administer medications during the
procedure.
• May continue to take medication: e.g. Heart diseases, HTN, DM with
a little of water.

16. • informed consent form that gives patient/guardian permission for the
procedures.
• Asked allergic to any medications, especially antibiotics , iodine or
radiological contrast media.
• ECG leads may be placed on chest & a BP cuff placed on arm to
monitor heart rate & blood pressure during the procedure.
• Recording of Oxygen level & vitals.

17. Premedication
• Hyoscine N butyl bromide 20 mg IM.
• Diazepam 10 mg I/V.
• Continue broad spectrum antibiotics

18. Contrast Medium
• LOCM 150mg I ml, 20-60 ml.
• Sedative: Midazolam and Analgesic: Lidnocane 3%

19. Equipment
• Ultrasound Machine, Fluroscopic Unit with spot film device and tilting table.
• Chiba needle (flexible 18 -22 G, 15-20 cm long, with stainless steel needle.
21F , 15cm long with with outer and inner diameter
0.7 and 0.5 mm respectively).
• Betadine, cotton swabs, sterile gloves, forceps.
• Local anaesthetic injection: Lignocaine 2%.
• Guide wires, Dilators, Metallic stents.
• Catheters:
Exterior drainage catheters
Internal drainage catheters
Balloon dilatation catheters

20. 20
PTCD: Equipments Required
Chiba needles Drainage catheter

21. Equipment Required
• Vascular Ascess Sheath and dilators

22. J tipped Stiff Guidewire

23. Must Required
• Duct must have been dilated

24. Preliminary Imaging
• US to confirm position of liver and dilated ducts.

25. Patient Position/Location
○ Right/left/bilateral drainage may be performed
○ Right-sided access generally preferred
– Straighter course for wire/catheter manipulation
– May have higher radiation exposure to operators’ hands with left-
sided access
○ For PTBD, appropriate lobe to drain depends on
– Site of obstruction
□ Right or left drainage usually sufficient for distal
common duct obstruction
□ If confluence obstruction, may perform bilateral
drainage or unilateral drainage of larger lobe

26. Right PTC/PTBD access
– Patient supine on fluoroscopy table
– Right mid-axillary line approach
– 9th to 11th intercostal space
□ Ask patient to take deep breath; prefer access below lung margin
– Advance needle, initially parallel to table, toward T12 vertebral
body
□ Alternatively, may access dilated duct directly using ultrasound
guidance, if visible

27. Left PTC/PTBD access
○ Patient supine on fluoroscopy table
– Subxiphoid or subcostal approach
– Visualize dilated duct with ultrasound
□ If accessible, segment II duct preferred: Forms less
acute angle with left main duct
□ Segment III duct courses vertically; may be more
accessible than segment II duct

28. Technique
• Obtain IV access: give antibiotics, sedation and analgesia.
• patient is placed in a supine position, and sterile preparation and draping are
performed.
• Puncture the duct: aim for a point where the duct is large enough to
accommodate the catheters and drains that you plan to use, but fewer
complications the more peripherally you puncture
• Through usg guidance chiba needle is inserted into dilated duct.
• Confirm intraduct position: free backflow of bile indicates that you are in the
duct; make sure you put a decent length of the 0.018-inch wire into the duct.
• Stellate from the Chiba needle is removed and once bile observed, a J tipped
stiff guidewire ( 150cm long. 0.035”) is inserted upto the area it could reach.

29. Technique
• Exchange the 0.018-inch wire for the 0.035-inch J wire: using the
coaxial set.
• Dilate a tract into the duct: Use 5F or 6F dilators, depending on the
size of catheter you intend to use.
• Introduce the catheter you hope to use to cross the stricture; most
operators use either a Cobra or a biliary manipulation catheter.
• Take a sample of bile: for microbiology ± cytology.
• Cross the stricture: this is often harder than it sounds. We usually start
with the curved hydrophilic wire. The process is similar to crossing a
stricture or occlusion in a blood vessel

30. Technique
• Confirm intraluminal position: always ensure that you are either in
the distal bile duct or through to the duodenum.
• Exchange for the Amplatz super-stiff wire: aim to have the wire into
the 3rd part of the duodenum.
• Confirm free drainage: make sure you do this before you attach the
catheter!
• Fix the drain catheter to the skin: there are many options for this; so
either use a suture or a proprietary skin fixation device.

31. • Contrast is injected to opacify the biliary system

32. Technique
Two approaches are used:
1. Right lateral (mid-axillary) approach.
2. Anterior, Subcostal or Left sided subxiphoid approach.

33. FEATURES RIGHT-SIDED PUNCTURE LEFT-SIDED PUNCTURE
1 Patient comfort
Painful , restricted patient
movement.
Less painful, Increased
patient
comfort.
2 Technical ease of puncture Diffcult Easy
3 Associated risk
Pleural transgression, injury to
intercostal neurovascular
bundle
-
4 Radiation exposure Less radiation to operator
Higher radiation exposure to
operator’s hands
5 Preferred duct Anterior sectoral duct
Segment three duct- antero-
inferior to
segment two duct.
6 Puncture site
Below 10th rib at mid-axillary
line
Subxiphoid or substernal.

34. Right lateral (mid-axillary) approach

35. Anterior, Subcostal or
Left Sided Subxiphoid Approach
ADVANTAGES
• Less complications than right puncture.
• Larger & horizontal course with constant anatomy of left biliary
duct makes target easier.
• No risk of pleural puncture.
• Straight & short course through the liver makes easier placement
of the guide-wires, stents & balloons.

36. Anterior, Subcostal or
Left Sided Subxiphoid Approach
ADVANTAGES
• Less pain with movement or breathing as external drainage
catheters do not pass between the ribs.
• Easier to manage, cleaning & dressing the catheter by the patient- so
less likely to be dislodged.
• No diaphragmatic puncture therefore no irritation unlike right
approach.

37. Anterior, Subcostal or
Left Sided Subxiphoid Approach
DISADVANTAGES
• The major entry site (Lt. Medial segment duct) curvature can make
difficult to pass large catheters, dilators.
• Increased radiation exposure to the operator’s hands.
• Chance of false localization of level of obstruction.
• Opacification of left anterior duct can be difficult in supine
position.
• Shorter tract: less compressing effect, greater chance of bleed or
bile leakage .

38. Percutaneous Transhepatic Cholangiography and Drainage
(PTCD)
PTBD: External Drainage
• This is achieved
following Trashepatic
cannulation of the
biliary tree.
• Used to reduce
operative morbidity in
jaundiced patient.

40. • Various Biliary Drain catheter are used .
•For External drainage, suitable catheter
can be inserted over the wire after the sheath
is withdrawn.
• Commonly used catheters have a
retaining pigtail loop with holes.
• The internal fixation is achieved by using
a loop-retaining suture.
• Succesful Biliary drainage is defined as
placement of tube or stent to provide continuos drainage of bile.

41. PTBD: Internal Drainage
• Achieved following transhepatic or endoscopic cannulation of biliary
tree.
• Preferable because of the complication of long term transhepatic
catheterization.
• Insertion of catheter or bypass stent in the bile duct draining either
externally or long time for internally to relieve pressure remains in
place for further few days until the icterus & clinical features
subsided.

44. • For internal drainage or stent insertion the wire and 10 f Flixible Biliary
drainage catheter must be passed through the stricture into the
duodenum. A varieties of catheter wires are needed to pass the
barrier.

47. Major Complication
• Sepsis
• Haemorrhage
• Localised Inflammatory/Infectious
• Abscess, peritonitis,cholecystitis, Pancreatitis
• Dislodgement of catheter
• Blockage of Cathetar
• Perforation of bile duct above the stricture on passage of guidewire
• Death
• Pleural effusion, Pneumothorax in rt approach

49. After Care
• Bed Rest
• Pulse and Blood pressure measurement half hourly for 6 hrs.
• Antibiotic Prophylaxis for atleast 3 days.
• An External draining catheter should be flushed through with normal
saline and exchanged at every three months.

50. • Advice for rest: right lateral to give compression to punctured site.
• Close observation for 24 hours.
• Vital signs recorded half hourly for 12- 24 hours.
• Checking of punctured site for bleeding, leakage of bile, intra-
peritoneal haemorrhage & any sign of peritonitis at the same time.

51. • The bile in the collection bag also checked for colour, amount,&
presence of blood,
• Several doses of antibiotic medication through IV to prevent infection.
• Continue antibiotics for further few days.

52. If the patient is discharged with a catheter in place, teach how
to :
• care for the catheter at home.
• change the bandage around the catheter.
• do daily irrigations through the tube (flushing the catheter with
sterile water).
• showering or bathing safely.

53. THANK YOU

54. Q. Identify ?

55. Q. Describe ?

56. Q.Describe?

57. Q. Which of the following is false about
klatskin tumour?
a) a term that was traditionally given to a hilar cholangiocarcinoma,
occurring at the bifurcation of the common hepatic duct.
b) PTC is gold std to diagnosis of hilar choalngocarcinoma.
c) In Usg increased echogenicity relative to surrounding liver is most
common findings.
d) The Bismuth-Corlette system is one classification.

58. Q. All of the following are true except?
a) Rt sided approach is painful than left sided approach.
b) Left sided approach having less radiation exposure to operator hand
than right approach.
c) Rt sided approach puncture site below 10th rib at mid-axillary
line.
d) In rt sided approach more injury to intercostal neurovascular
bundle than left sided approach.