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%.