Sunday, October 1, 2017

Imaging Percutaneous Transhepatic Biliary drainage

Percutaneous Transhepatic Biliary Drainage
Objective
   Drainage of obstructed biliary systems in cases of surgical obstructive jaundice
   To treat cholangitis
   Gain access to biliary tract for stone removal, stricture dilatation, stent placement.
Patient Preprocedure Preparation
   Blood prothrombin time
   Antibiotic cover 24 hours prior to procedure
   Fasting for 6 hours
   IV fluids and serum electrolytes baseline values
   Surgical cleaning and draping of abdomen and right flank.
Position
Supine.
Anesthesia
   IV sedation with diazepam
   Local infiltration analgesia with 10 ml of 1% xylocaine
   General anesthesia may be required in uncooperative patients.
Instruments
   22 G, 20 cm long Chiba needle with stilet.
   18 G, 20 cm long PVC sheathed needle with stilet.
   0.035" or 0.038" diameter, 100 cm long J-shaped guidewire.
   0.038" heavy duty straight guidewire.
   Sterile surgical blades.
   Graded teflon dilators 7F-10F.
   Ring biliary drainage catheter 10F pigtail with multiple side holes extending about 10 cm above the pigtail.
   Suture and needle for fixation of catheter.
   Adhesive tape.
   Connector.
   3-way stopcock.
   Collection bag.
   Water soluble iodinated contrast 50-100 ml.
   Syringes 20 ml, 10 ml.
   Normal saline.
Procedure
   1.  Fluoroscopic guidance.
   2.  Patient positioned supine, right side toward operator.
   3.  Puncture site is in midaxillary line, choose intercostal space below maximum excursion of diaphragm.
   4.  Local analgesia infiltration.
   5.  Puncture intercostal space with 22 G neelde under fluoro­scopic guidance; direct needle toward Xiphisternum till the midline; remove stilet.
   6.  Perform cholangiography by injecting diluted (1:1) contrast while continuously withdrawing the needle.
   7.  As soon as bile ducts are opacified; stop withdrawing needle and inject more contrast till the entire biliary tree is opacified.
   8.  If no bileduct is opacified in the first attempt, repeat the procedure as above.
   9.  Once the biliary tract is opacified, under continuous fluoroscopic monitoring insert the 18 G sheathed needle through the same intercostal space to puncture a peripheral right lobe bile duct preferably a posterior branch.
10.  Withdraw stilette of needle-sheath assembly.
11.  Position of needle tip within a duct is confirmed by injecting few ml of contrast.
12.  Make a stab incision along needle.
13.  Remove cannula leaving the sheath in place.
14.  Insert guidewire through sheath into the biliary tract.
15.  Manipulate the guidewire into desired position if possible.
16.  Dilate tract over guidewire to 10F size.
17.  Insert biliary drainage catheter.
18.  Position catheter so that all sideholes are within the biliary tract/hepatic parenchyma.
19.  Remove guidewire.
20.  Connect catheter to collection bag.
21.  Suture catheter and skin wound.
22.  Secure catheter to skin wound.
23.  Secure catheter to skin with adhesive tape.
Complications
   Bleeding
   Biliary peritonitis
   Cholangitis and septicemia
   Electrolyte imbalance
   Pneumothorax.
            *Alternatively, sonographic guidance can be used for perform­ing PTBD. This is specially indicated if the left sided ducts need to be drained. Puncture is made directly with the 18 G sheathed needle through the epigastrium. The remaining steps (10-22) are same as in the fluoroscopic guided technique.


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