Introduction
Percutaneous Transhepatic Biliary Drainage (PTBD) is a minimally invasive, image-guided procedure performed by interventional radiologists to relieve biliary obstruction by creating an external or internal drainage route.
It plays a crucial role in managing malignant and benign biliary strictures, especially when endoscopic retrograde cholangiopancreatography (ERCP) is not feasible.
Principle
- PTBD involves percutaneous puncture of a bile duct under imaging guidance, insertion of a drainage catheter, and decompression of the biliary system.
- The goal is to reduce bilirubin levels, relieve cholangitis, and prepare patients for surgery, chemotherapy, or palliative care.
Indications
- Malignant biliary obstruction (cholangiocarcinoma, pancreatic cancer, metastases)
- Failed ERCP cannulation
- Biliary leaks post-surgery
- Benign strictures not amenable to endoscopic therapy
- Preoperative decompression for high-risk surgical candidates
Contraindications
- Uncorrectable coagulopathy (INR > 1.5, platelets < 50,000)
- Severe ascites (relative, requires drainage)
- Unstable patients without ability to tolerate sedation
Procedure Technique
- Pre-procedure Preparation – Labs (LFTs, coagulation), imaging (US, CT, MRI/MRCP), antibiotics.
- Imaging Guidance – Ultrasound to identify dilated ducts; fluoroscopy for wire and catheter placement.
- Duct Puncture – Using a fine needle through the liver parenchyma into a peripheral bile duct.
- Cholangiography – Contrast injection to outline obstruction site.
- Drainage Placement – External drainage catheter, or internal-external drain across the obstruction.
- Securing the Catheter – Prevents dislodgement, connects to drainage bag if external.
Post-Procedural Care
- Monitor for bleeding, bile leak, sepsis
- Maintain catheter patency (flushing as per protocol)
- Gradual bilirubin decline expected within days
- Follow-up imaging for catheter position
Complications
- Hemobilia (due to vascular injury)
- Cholangitis or sepsis
- Bile leak and peritonitis
- Catheter blockage or dislodgement
Advantages
- Life-saving in acute cholangitis with failed ERCP
- Enables further oncologic management by lowering bilirubin
- Can be converted to internal stenting in select cases
Long-Term Role
- Palliative care for unresectable malignancies
- Bridge to surgery or liver transplantation
- Used in combination with biliary stenting for internal drainage
Key Takeaways
- PTBD is an essential IR tool for urgent and elective biliary decompression.
- Requires a multidisciplinary approach with hepatobiliary surgeons and gastroenterologists.
- Technical success depends on precise imaging-guided access and post-procedure care.
