Percutaneous Transhepatic Biliary Drainage (PTBD)
A Percutaneous Transhepatic Biliary Drainage is a percutaneous therapeutic procedure which leads to the drainage of the obstructed bile duct system. Doctors request a PTBD to aid in the treatment of jaundice if no other option is preferable. Other options might be endoscopy and surgery. If endoscopy is not possible and if the patient is inoperable, then the percutaneous access is indicated.
The underlying disease of jaundice might be a malignancy of the bile ducts itself, of the pancreas head or of adjacent organs or structures, like lymphnodes, the gallbladder or the stomach. Also benign reasons like biliary stones or strictures after surgery can lead to jaundice and might need a percutaneous drainage.
The drainage of the bile ducts is performed with a small plastic catheter. The catheter is placed internally across the narrowed duct, having an external end connected to a drainage bag. The catheter is secured to the skin with sutures.
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The drainage procedure can be extended with the placement of a permanent metallic device, called stent, which keeps the biliary ducts open without any need for a catheter.
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| Figure 1 |
Apart from the local anaesthetic injection, which stings momentarily, the examination should be pain free. One may experience some discomfort as the contrast is injected into the biliary ducts, but this wears off very quickly.
The staff helps the patient for this therapeutic procedure:
• The doctors will take a blood sample and send this to the laboratory for testing.
• On the day of the examination an intravenous line will be inserted into an arm vein.
• One hour prior to the examination intravenous antibiotics will be given through this line.
• On the day of the examination an intravenous line will be inserted into an arm vein.
• One hour prior to the examination intravenous antibiotics will be given through this line.
• It is not allowed to eat for four hours before the examination, but one may drink clear fluids.
• Patient will be asked to wear a hospital gown.
• Patient will be given the opportunity to ask questions about the procedure before signing a consent form.
• Patient will be asked to wear a hospital gown.
• Patient will be given the opportunity to ask questions about the procedure before signing a consent form.
• The patient will be asked to lie on his/her back on an examination table with the right arm away from the side of your body
(above your head).
• Monitoring equipment will be attached; this will measure the blood pressure, heart rate and oxygen saturation.
• The skin will be cleaned with an antiseptic skin preparation lotion.
• An x-ray camera will be used to locate the best position for the procedure.
• Local anaesthetic will be administered into the skin.
• The x-ray is then used to help the radiologist locate the bile ducts, so that contrast media can be injected into them, and visualised on the TV monitor. At intervals static images will be taken of the ducts.
• Monitoring equipment will be attached; this will measure the blood pressure, heart rate and oxygen saturation.
• The skin will be cleaned with an antiseptic skin preparation lotion.
• An x-ray camera will be used to locate the best position for the procedure.
• Local anaesthetic will be administered into the skin.
• The x-ray is then used to help the radiologist locate the bile ducts, so that contrast media can be injected into them, and visualised on the TV monitor. At intervals static images will be taken of the ducts.
It may not be possible to cannulate the bile ducts, therefore other imaging techniques may need to be considered.
There may be a narrowing in one or more of the ducts that will require drainage or further intervention, such as balloon dilatation or stent placement.
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| Figure 2 | Figure 3 | ||
Figure 2: The percutaneous catheter is pushed through the stenosed common bile duct, so that bile is advanced inside the catheter towards the bowel loops.
Figure 3: Metallic Stent is placed into the common bile duct, keeping the stenosed area patent. Now the percutaneous catheter can be taken out.
The whole procedure may last 1-2 hours, depending on the grade of difficulty and the cooperation of the patient. Deep sedation and analgesia might be needed for that purpose. Optimally, the initial drainage can be combined with the stent placement in one session. Then the catheter kept in place for security reasons, might be retrieved 1-2 days later, after full expansion of the stent. The stent can expand better and quicker if the malignant stricture is dilated before or immediately after stent placement.
Procedure related complications like stent misplacement or migration can be corrected by placement of a second stent.
Other complications are rare, but you may have:
• Mild post procedural pain for which analgesia will be given
• Mild post procedural pain for which analgesia will be given
• Infections which can be treated with antibiotics
• Bleeding (very uncommon)
This depends on the type of procedure the Radiologist performs. Generally patient is kept in the Hospital for several days until he/she recovers.
• The blood pressure and pulse will be monitored.
• The Haematocrit will be checked.
• The catheter site will be checked frequently.
• Patient can eat and drink normally, or as instructed by the Doctors.
• He/she must be careful not to dislodge the catheter
The technical success of the procedure depends on the experience of the Interventional Radiologist performing the drainage. It can be as high as nearly 100%. Clinical efficacy is usually lower but still over 90%.
Stent patency depends on the cause and the site of the stenosis. It can reach 6-12 months depending on several parameters.
1. Adam A (1994) Metallic biliary endoprostheses. Cardiovasc Intervent Radiol 17:127-132
2. Salomonowitz EK, Antonucci F, Heer M, Stuckmann G, Egloff B, Zollikofer CL (1992) Biliary obstruction: Treatment with self-expanding metal prostheses. J Vasc Interv Radiol 3:365-370
3. Coons H (1992) Metallic stents for the treatment of biliary obstruction: A report of 100 cases. Cardiovasc Intervent Radiol 15:1367-1374
4. Stoker J, Lameris JS (1993) Complications of percutaneously inserted biliary Wallstents. J Vasc Interv Radiol 4:767-772
5. Rossi P, Bezzi M, Rossi M, Adam A, Chetty N, Roddie ME, Iacart V, Cwikiel W, Zollikofer CL, Antonucci F, Boguth L (1994) Metallic stents in malignant biliary obstruction: Results of a Multicenter European Study of 240 patients. J Vasc Interv Radiol 5:279-285
6. Doctor N, Dick R, Rai R, Dafnios N, Salamat A, Whiteway H, Dooley J, Davidson BR (1999) Results of percutaneous plastic stents for malignant distal biliary obstruction following failed endoscopic stent insertion and comparison with current literature on expandable metallic stents. Eur J Gastroenterol Hepatol 11:775-780
7. A. Hatzidakis, D. Tsetis, E. Chrysou, E. Sanidas, J. Petrakis, N. Gourtsoyiannis (2001) Nitinol stents for palliative treatment of malignant obstructive jaundice. Should we stent the sphincter of Oddi in every case?CardioVascular and Interventional Radiology, 24: 245-248.
Partly taken from www.sirweb.org
edited by A.Hatzidakis
May 2005