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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