Overview of Percutaneous Transhepatic Cholangiography with Biliary Drain Placement
A Percutaneous Transhepatic Cholangiogram (called PTHC for short) is a minimally invasive procedure to image the liver’s bile ducts. The biliary drain is the part of the procedure to help drain your bile ducts if they are blocked. The bile ducts are tubes that connect your liver to your intestine. Bile is an important liquid in your body that not only helps digest food but helps get rid of toxins from your blood that will be excreted in your intestines. If your bile ducts are blocked, the liver will get damaged and eventually fail if the ducts are not unblocked. There are many reasons for your bile ducts to get blocked. For example, stones from your gallbladder can block your bile ducts. Other causes include diseases like primary sclerosing cholangitis, post-surgical strictures (tight scarring of the ducts), and cancers.
Indications for PTHC with biliary drain placement:
The most common reason for a biliary drain placement is obstruction of the bile ducts for any reason. For many people, our gastroenterology (GI doctors) colleagues can relieve the obstruction with biliary drainage placement with an endoscope in a procedure called an endoscopic retrograde cholangiopancreatography (ERCP). This is generally the first step for many people because it does not involve any incisions through the skin or puncturing through the liver. If they are unable to perform the ERCP or the procedure fails, the next step is generally for us to perform the PTHC with biliary drain placement. This is done in the interventional radiology suite with imaging guidance. Other common indications include:
- Biliary stone retrieval
- Evaluation of complications of ERCP, such a bile leak
- Postoperative stricture dilatation with or without drain placement
- Identify any cause of obstructive jaundice
- Afferent loop syndrome after gastric bypass
After you are cleaned, draped and anesthesia has begun, we generally use ultrasound or X-Ray fluoroscopy to localize your liver and identify your bile ducts. A two-part thin needle is then inserted into one of your peripheral bile ducts generally under ultrasound guidance. One we believe we are in the bile duct, we inject a small amount of contrast (dye) to ensure we’re in the bile duct. Once we’re in, we may take more extensive pictures of the biliary system depending on the indication. If a biliary drain is indicated, we place a wire through a needle. After a few steps of dilation, we thread a catheter over the wire to drain the bile. This is generally secured at your skip with a non-absorbable stich and dressing.
Different versions of Biliary drains:
Internal/external biliary drain:
For this drain, tube travels from the skin in your back to the bile ducts in your liver and then generally down the common bile duct to your duodenum (first part of the intestines). This is the most common tube placed because the tube can bypass whatever blockage there is in your bile ducts. The bile can drain from holes within the part of the tube in your liver to the holes in your intestine. That means many people can have the outside of their tube capped and not have the bile drain to a bag. This is because the bile is flowing within the tube to your intestines. The outside of the tube is still needed to be cared for, because that is how we’ll re-access your bile ducts to change the tube or take it out.
External biliary drain:
Some people are not able to have the part of the tube extend all the way inside to their intestines. This is generally due to your anatomy, whether it’s a post-surgical narrowing or there’s a blockage or mass that obstructs the path to your intestines. This means the tube extends from the bile ducts in your liver to drain out of the collection bag on your side. These can’t be capped because it’s the only way for your bile to drain.
Caring for your biliary drain:
After completing the procedure, our team and your nurse will generally counsel you on how to care for your biliary drain. Depending on your situation, this may drain externally to a bag that you’ll empty or you’ll be able to have it capped on the outside and not have to worry about drainage. We also teach you how to flush your tube with normal saline (basically salt water), so that it stays open. You’ll generally come back to have your drain exchange every 2-3 months, so that the drain doesn’t clog.