Percutaneous transhepatic cholangiography: Difference between revisions

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{{Short description|Medical imaging of the biliary tract}}

{{redirect|PTHC|pre-teen hardcore|Child pornography}}

{{Infobox interventions |

Name = Percutaneous transhepatic cholangiography |

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synonyms = Percutaneous hepatic cholangiogram|

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'''Percutaneous transhepatic cholangiography''' ('''PTHC''' or '''PTC'''), '''percutaneous hepatic cholangiogram''', or '''percutaneous transhepatic cholangiography and drainage''' ('''PTCDPTHC''') is a radiological technique used to visualize the [[anatomy]] of the [[biliary tract]].<ref>{{Citation |last1=Young |first1=Michael |title=Percutaneous Transhepatic Cholangiogram |date=2023 |url=https://www.ncbi.nlm.nih.gov/books/NBK493190/ |work=StatPearls |access-date=2023-11-24 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29630242 |last2=Mehta |first2=Dhruv}}</ref> A [[contrast medium]] is injected into a bile duct in the [[liver]], after which [[X-ray]]s are taken. It allows access to the biliary tree in cases where [[endoscopic retrograde cholangiopancreatography]] (ERCP) has been unsuccessful. Initially reported in 1937, the procedure became popular in 1952.<ref>{{cite journal |vauthors=Carter RF, Saypol GM |title=Transabdominal cholangiography |journal=Journal of the American Medical Association |volume=148 |issue=4 |pages=253–5 |year=1952 |pmid=14888454 |doi=10.1001/jama.1952.02930040009002}}</ref><ref>{{cite journal |vauthors=Atkinson M, Happey MG, Smiddy FG |title=Percutaneous transhepatic cholangiography |journal=Gut |volume=1 |issue= 4|pages=357–65 |year=1960 |pmid=13684978 |pmc=1413224 |doi=10.1136/gut.1.4.357}}</ref>

==TechniqueUses==

Some uses for this procedure includes: drainage of bile/infected bile to relieve [[obstructive jaundice]], to place a stent to dilate a stricture in the biliary system, stone removal, and rendezvous technique<ref name="Chapman 2018">{{cite book | vauthors = Watson N, Jones H |title=Chapman and Nakielny's Guide to Radiological Procedures |date=2018 |publisher=Elsevier |isbn=9780702071669 |pages=111-112, 112-113, 117-118}}</ref> where guidewire from the [[common bile duct]] (CBD) meets with duodenoscope (coming from the oesophagus into the stomach and then duodenum) at the [[major duodenal papilla]]. In this rendezvous technique, the guidewire is then pulled into duodenoscope and a small blade is slid over the guidewire into the CBD and perform surgeries on a specific bile duct in the biliary system.<ref name="Ayala 2008">{{Cite journal |last1=Ayala |first1=Juan C. |last2=Labbe |first2=Ricardo |last3=Vera |first3=Juan E. |date=April 2008 |title=SHORT (SHOrt Rendezvous Technique): A New ERCP Rendezvous Technique |url=https://linkinghub.elsevier.com/retrieve/pii/S0016510708007682 |journal=Gastrointestinal Endoscopy |language=en |volume=67 |issue=5 |pages=AB159–AB160 |doi=10.1016/j.gie.2008.03.351|url-access=subscription }}</ref> PTHC is frequently performed guide therapy of the biliary system. Rarely it is used for diagnostic purposes only.<ref name="Chapman 2018"/>

It is predominantly now performed as a therapeutic technique. There are less invasive means of imaging the biliary tree including transabdominal ultrasound, [[magnetic resonance cholangiopancreatography]], [[computed tomography]] and [[endoscopic ultrasound]]. If the biliary system is obstructed, PTC may be used to perform [[biliary drainage]] until a more permanent solution for the obstruction is performed (e.g. surgery). Additionally, self expanding metal stents can be placed across malignant biliary strictures to allow palliative drainage. Percutaneous placement of metal stents can be utilised when therapeutic ERCP has been unsuccessful, anatomy is altered precluding endoscopic access to the duodenum, or where there has been separation of the segmental biliary drainage of the liver, allowing more selective placement of metal stents.

PTHC is also used in the drainage of unruptured or uncomplicated hydatid cysts. Rarely, PTHC is used in the drainage of ruptured hydatid cysts.<ref>{{Cite journal |last1=Inal |first1=Mehmet |last2=Soyupak |first2=Süreyya |last3=Akgül |first3=Erol |last4=Ezici |first4=Hüseyin |date=2002-10-01 |title=Percutaneous Transhepatic Endobiliary Drainage of Hepatic Hydatid Cyst with Rupture into the Biliary System: An Unusual Route for Drainage |url=http://link.springer.com/10.1007/s00270-001-0091-x |journal=CardioVascular and Interventional Radiology |volume=25 |issue=5 |pages=437–439 |doi=10.1007/s00270-001-0091-x |issn=0174-1551|url-access=subscription }}</ref>

Cholangiography during a [[Bile_duct#Drainage|biliary drainage]] intervention is called ''perioperative'' or ''primary'' choloangiography, and when performed later in the same drain it is called ''secondary'' cholangiography.<ref name="SchuberthSjogren2010">{{cite journal|last1=Schuberth|first1=O. O.|last2=Sjogren|first2=S. E.|title=On Cholangiography|journal=Acta Radiologica|volume=22|issue=5-6|year=2010|pages=780–795|issn=0001-6926|doi=10.3109/00016924109136457}}</ref>

==Contraindications==

==Indications==

Among the contraindications are: increased [[bleeding tendency]] where platelets less than 100x10⁹/litre and prothrombin time prolonged more than 2 seconds than the control. This procedure is also contraindicated in biliary tract sepsis, except to control the infection by drainage of the infected bile.<ref name="Chapman 2018"/>

Cholestatic jaundice, to exclude extra hepatic bile duct obstruction, prior to biliary drainage procedure.

==Technique==

If ERCP is failed and/or there is an obstruction in the proximal billiary tree

Low osmolar contrast medium is used in this procedure with concentration of 150 mg/ml with 20 to 60 ml volume. Those who undergoes the procedure needs to be fasted for four hours before the procedure. Besides, antibiotics such as [[ciprofloxacin]] 500 mg to 750 mg can be given as [[antibiotic prophylaxis]] to prevent infection during the procedure. [[Sedation]] (to reduce irritability and agitation of the subject during procedure) with [[analgesia]] (painkillers) and vital signs monitoring should be set up. Before the procedure, bedside ultrasound is done to confirm the position of the dilated bile ducts in the liver. The puncture site is then marked. Bile ducts of the right liver is located in the intercostal spaces between anterior and mid axillary lines. Meanwhile, the bile ducts in the left lobe of the liver is located to the left side of the [[xiphisternum]] on the [[epigastric]] region.<ref name="Chapman 2018"/>

The number of attempts made to pass Chiba needle into the biliary tract does not affect the rate of complication but the likehood of success is related to the degree of dilatation of the biliary tract (larger dilatation means needle is easier to find its way into the biliary tract) and total number of attempts made.<ref name="Chapman 2018"/>

==Contraindications==

* [[Bleeding tendency]]

Excessive contrast media injection into the liver should be avoided. When there is excessive injection into the liver, lymphatics within the liver will be opacified with contrast medium. Injection of the contrast medium into an artery or vein will cause the contrast to dispersed quickly due to blood flow.<ref name="Chapman 2018"/>

* [[Biliary tract]] [[sepsis]]

* Being unfit for surgery

Cholangiography during a [[Bile_ductBile duct#Drainage|biliary drainage]] intervention is called ''perioperative'' or ''primary'' choloangiography, and when performed later in the same drain it is called ''secondary'' cholangiography.<ref name="SchuberthSjogren2010">{{cite journal|last1=Schuberth|first1=O. O.|last2=Sjogren|first2=S. E.|title=On Cholangiography|journal=Acta Radiologica|volume=22|issue=5-65–6|year=2010|pages=780–795|issn=0001-6926|doi=10.3109/00016924109136457}}</ref>

* [[Echinococcus|Hydatid]] cysts

* [[Ascites]]

* CLD ([[Chronic liver disease]])

==Complications==

PTBDPercutaneous transhepatic cholangiography may increase the incidence of metastasis, tube dislocation, and bleeding when compared to endoscopic biliary drainage (EBD). However, PTBDit has lower rate of cholangitis, pancreatitis when compared to EBDendoscopic biliary drainage, probably because EBDthe latter has higher chance of incomplete drainage of infected bile, or accidental resection of papilla that causes the backflow of infected bile from the duodenum into the biliary system.<ref>{{Cite journal |lastlast1=Duan |firstfirst1=Feng |last2=Cui |first2=Li |last3=Bai |first3=Yanhua |last4=Li |first4=Xiaohui |last5=Yan |first5=Jieyu |last6=Liu |first6=Xuan |date=December 2017 |title=Comparison of efficacy and complications of endoscopic and percutaneous biliary drainage in malignant obstructive jaundice: a systematic review and meta-analysis |url=http://cancerimagingjournal.biomedcentral.com/articles/10.1186/s40644-017-0129-1 |journal=Cancer Imaging |language=en |volume=17 |issue=1 |pages=27 |doi=10.1186/s40644-017-0129-1 |issn=1470-7330 |pmc=PMC56441695644169 |pmid=29037223 |doi-access=free }}</ref><ref>{{Cite journal |lastlast1=Wang |firstfirst1=Lei |last2=Lin |first2=Nanping |last3=Xin |first3=Fuli |last4=Ke |first4=Qiao |last5=Zeng |first5=Yongyi |last6=Liu |first6=Jingfeng |date=December 2019 |title=A systematic review of the comparison of the incidence of seeding metastasis between endoscopic biliary drainage and percutaneous transhepatic biliary drainage for resectable malignant biliary obstruction |url=https://wjso.biomedcentral.com/articles/10.1186/s12957-019-1656-y |journal=World Journal of Surgical Oncology |language=en |volume=17 |issue=1 |pages=116 |doi=10.1186/s12957-019-1656-y |issn=1477-7819 |pmc=PMC66121066612106 |pmid=31277666 |doi-access=free }}</ref>

==Percutaneous transhepatic biliary drainage==

Percutaneous transhepatic biliary drainage (PTBD) is often performed if endoscopic retrograde biliary drainage (ERBD) is unsuccessful for biliary obstructions due to [[hepatocellular carcinoma]]. ERBD is the first line treatment because of its low bleeding risk. For biliary obstruction at the hilum (meeting point of right and hepatic hepatic ducts), both ERBD and PTBD can be done depending on subject's clinical circumstances and physician's preference.<ref>{{Cite journal |last1=Kolev |first1=Nikola Y. |last2=Ignatov |first2=Valentin L. |last3=Tonev |first3=Anton Y. |date=2013-11-20 |title=Biliary Drainage |url=http://www.journal-imab-bg.org/issue-2013/issue3/vol19book3p465-469.html |journal=Journal of IMAB - Annual Proceeding (Scientific Papers) |volume=19 |issue=3 |pages=465–469 |doi=10.5272/jimab.2013193.465|doi-access=free }}</ref>

==Percutaneous extraction of retained biliary calculi==

===Percutaneous transhepatic technique===

This procedure is indicated when [[endoscopic retrograde cholangiopancreatography]] (ERCP), papillotomy (cutting through [[major duodenal papilla]] to relieve stenosis) or stone removal are unsuccessful. This procedure is also indicated when endoscopic access is difficult in case where there is major modification of the stomach and small intestine such as [[Billroth II]] stomach resection, and other conditions such as intradiverticular papilla (duodenal papilla located inside a duodenal outpouching), stenosis of the duodenal papilla, stone within the distal CBD, stenosis of [[ampulla of Vater]], stone in the peripheral bile duct, or stone larger than 15 mm.<ref name="Ilgit 2002">{{Cite journal |last1=Ilgit |first1=Erhan T |last2=Gürel |first2=Kamil |last3=Önal |first3=Baran |date=September 2002 |title=Percutaneous management of bile duct stones |url=https://linkinghub.elsevier.com/retrieve/pii/S0720048X02001596 |journal=European Journal of Radiology |language=en |volume=43 |issue=3 |pages=237–245 |doi=10.1016/S0720-048X(02)00159-6|url-access=subscription }}</ref>

Biliary calculi is seen on cholangiogram done on T-tube that was previously inserted into CBD. This happens in 3% of the cases post surgical management of biliary stones. This procedure is contraindicated if T-tube is too small (less than 12 French in size), tortous T tube in tissues, [[acute pancreatitis]], and when there is another drain that is connected to the T-tube tract.<ref name="Chapman 2018"/>

PTBD is done one to two weeks before the procedure to reduce oedema of the biliary ducts and [[sphincter of Oddi]] oedema.<ref>{{Cite journal |last1=Cheng |first1=Jhm |last2=Leung |first2=Wkw |last3=Wong |first3=Ahc |last4=Lee |first4=Bkh |last5=Leung |first5=Bst |last6=Chu |first6=Cy |last7=Kan |first7=Wk |date=2020-06-19 |title=Percutaneous Transhepatic Biliary Stones Removal — An Effective and Safe Alternative |url=https://www.hkjr.org/article/v23n2/106 |journal=Hong Kong Journal of Radiology |volume=23 |issue=2 |pages=106–113 |doi=10.12809/hkjr2016940|doi-access=free }}</ref>

Either high osmolar contrast medium or low osmolar contrast medium can be used (with concentration of 150 mg/ml). Low density contrast medium is used to prevent obscuring of the calculus. [[Antibiotic prophylaxis]] and pre-medication is given one hour before the procedure. Painkillers is given during the procedure. The subject lie down in supine position on the table. PTHC is performed if biliary drainage catheter is not in-situ. The drainage catheter is then removed over the guidewire and sheath is inserted into the ducts (7 to 8 French size). Contrast is then injected through the sheath to identify any stones or strictures. If a stricture is identified, put in biliary manipulation catheter with guidewire measuring 0.035 inches and commence balloon dilatation (with balloon sizes of 8, 10, and 12 mm). Using the balloon catheter, the stones are pushed into the duodenum. If the stones are difficult to push, Dormier basket is used to push them into the duodenum. The basket is removed and guidewire is inserted back into the sheath. The sheath is then removed and biliary drainage catheter is inserted back through the guidewire. Contrast is then injected intermittently through the drainage catheter to follow-up on the position of the stones.<ref name="Chapman 2018"/>

After the procedure, pulse and blood pressure are monitored half-hourly for six hours. The subject put on bed rest for a total of four to six hours.<ref name="Chapman 2018"/>

Possible complications include allergic reaction to the contrast and inflammation of the pancreas. There can also be perforation of the T-tube tract.<ref name="Chapman 2018"/>

===Trans T-tube technique===

Post-operative T-tube cholangiography is performed on the 10th day post operation where either high osmolar or low osmolar contrast media with concentration of 150 mg/ml with volume of 20 to 30 ml is injected through the T-tube to determine if there is any leak from the biliary tract or remaining stones within the biliary system.<ref name="Chapman 2018"/>

Trans T-tube technique of stone extraction also known as Burhene technique. This procedure is done after 5 to 8 weeks post abdominal operation for the maturation of the T-tube tract when fibrous tissue is formed at its walls to support the tract and keep the tract open.<ref name="Ilgit 2002"/> Guidewire is then advanced through the T-tube before the T-tube is removed. Then a catheter is inserted over the guidewire and cholangiogram is performed to visualise the anatomy of the biliary tract and the positions of the stones.<ref name="Ilgit 2002"/>

==References==

<references />

==External links==

* {{MedlinePlusEncyclopedia|003820}}

* [https://www.nlm.nihmedlineplus.gov/medlineplus/ency/article/003820.htm Medline page]

* [http://www.cpmc.org/learning/documents/pthcbiliarydrainage-ws.html Sutter Health Network page]

{{Digestive system surgical procedures}}

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[[Category:Projectional radiography]]

[[Category:Digestive system imaging]]

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