Editing Percutaneous transhepatic cholangiography

PTC

== Indications ==

* Benign biliary strictures
* Biliary ductal injuries and leaks
* Decompression of cholangitis
* Biliary duct biopsy
* Stone removal
* Palliation of malignant biliary obstruction
* Occasional endoluminal therapies such as radiation, photodynamic therapy, and drug infusion

== Contraindications ==

* Absolute
** Significant coagulopathy that cannot be corrected (platelets < 50 or INR >1.7)
* Relative
** Diffuse polycystic liver disease
** Hepatic cysts from parasitic infections
** Ascites - often persistent ascitic leak around tube which is very troublesome for patients

== Procedure ==

* Supine
* IV sedation and analgaesia for conscious sedation
* LA to entry site - costophrenic angle, midaxillary line (more medial if accessing left lobe)
* 22G needle used to inject contrast into liver and find bile duct
* Either internal/external biliary drainage catheter, or internal drainage catheter (generally for palliative unresectable disease)
* If there's an obstructing lesion, better to cross it with a stent rather than internal/external drainage from above, because you'll lose too much bile
* Internal/external catheters should be flushed once or twice daily - flush FORWARDS, not aspirating, so as to avoid bringing GIT flora into biliary system via negative pressure. These catheters need to be exchanged over a guidewire every 2 to 3 months

== Internal drainage ==

* Stents 
** Plastic (polymer)
*** Larger in calibre - 10F or 12F - theoretical risk of pain and bleeding
*** Cheaper
*** Majority are placed endoscopically
** Metal
*** Better for palliation - larger diameter, lasts longer, cheaper
*** Smaller in calibre at deployment - can use a 6F or 7F sheath system and expand to 1cm (SEMS)
*** Reduce risk of pancreatitis by placing suprapapillary rather than transpapillary
*** Generally lasts for 6-12 months without occluding
*** Covered seem to last longer than uncovered
**** Uncovered - tumour infiltration
**** Covered - tumour overgrowth at edges, sludge formation, stent migration
** Expanded PTFE (ePTFE) stents
*** In development, may improve long-term patency
* Often, can remove the transhepatic access straight away, but consider leaving internal/external drain if risk of bleeding due to friable tumour - allow you to go back in 2 days, check for occluding thrombus, then remove access

== Complications ==

* Haemobilia/haemorrhage
** 2-8%
** Usually a result of injury to a major vessel (hepatic artery or vein or PV)
** RUQ pain, bleeding from I/E drain, melena/haematochezia, etc
* Sepsis
* Biloma
* Peritonitis
* Pancreatitis
* Pleural effusions
* Death
* Leakage of bile around catheter
** Often due to catheter occlusion - may need to be exchanged
** Differentiate from ascites leaking - may be able to treat this with purse-string suture around catheter
* Excessive bile losses
** Occurs with complete distal obstruction
** Complications
*** Fluid and electrolyte depletion (see 'liver anatomy' for relevant electrolytes in bile). Can check concentration of solutes in bile vs urine to establish whether biliary losses are responsible.
*** Metabolic acidosis
*** Malabsorption
*** Diarrhoea
*** ADKI
** Management
*** Careful replacement of electrolytes/fluid
*** Octreotide to reduce bile production?
*** Exogenous bile salts
*** Recirculation (more cost-effective and reno-protective than giving exogenous bile salts)
** Indications for recirculation
*** Losses >1.5L/day (as per YO)
*** Refractory hyponatraemia or other fluid/electrolyte problems
** Contraindications
*** Suspected infection in bile (based on observation of colour, or other factors including isolation of resistant organisms on culture and high bacterial counts on microscopy)
** Recirculation route
*** Orally - not palatable, nausea-inducing - can mix with fizzy drinks
*** Naso-enteral tube
** Benefits
*** Reduction in serum bilirubin
*** Possibly improved host defences 
*** Improved gut function
*** The overall level of evidence is low, with no prospective RCTs


== Removal of biliary catheter ==

* If benign stricture, reassess after 6-12 months whether it can come out
* Over-the-wire cholangiogram prior to removal to assess whether the duct looks patent
* Can place a drainage catheter above the site of previous obstruction to see whether bile is flowing down, then remove after 1-2 weeks if successful. Can quantify this with a biliary manometric perfusion test - pressures of <20cm H2O are considered normal, predictive value of patent duct at 1 year approaches 90%.

[[Category:HPB]]