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Percutaneous transhepatic cholangiography (PTC)

Percutaneous transhepatic cholangiography is a diagnostic procedure that involves the sterile placement of a small gauge needle into peripheral biliary radicles with use of imaging guidance, followed by contrast material injection to delineate biliary anatomy and potential biliary pathologic processes. PTC is often done for biliary drainage

What are the indications of PTC?

Indications (PTC is done when ERCP has failed)

  • Decompress obstructed biliary tree
  • Dilate biliary strictures
  • Remove bile duct stones, when ERCP fail
  • Divert bile from bile duct leak and stent bile duct defect

Discuss the technique of PTC?

  • The patient lies supine and the local area is infiltrated with local anaesthetic.
  • Under fluoroscopic control, a needle is introduced into the liver. The stillette is withdrawn from the needle and a syringe containing contrast media attached, contrast media is injected under fluoroscopic control as the needle is slowly withdrawn until a duct is demonstrated. This may require several manipulations of the needle.
  • Then the contrast media is injected to fill the ductal system and identify the level of obstruction.
  • Following the contrast injection, the radiologist guides a small guide wire through the needle, into the ducts and across the site of blockage while watching the wire and ducts on x-ray.
  • Over this wire, a small tube (catheter) is then inserted to allow the bile to be drained from the liver, relieving the jaundice caused by blockage of the duct.
  • Three types of drainage procedure can be performed
    • External drainage: a percutaneous catheter is placed into the bile ducts above the lesion. The bile can then drain away into a bag outside the body
    • Internal/external drainage: a percutaneous catheter (with side holes) is placed with the tip in the duodenum
    • Internal drainage: using a totally internal prosthesis (plastic or metal stent)

External drainage is not preferred as the catheters are prone to dislodgement. Catheter dislodgement is a serious complication as this can result in bile leak and biliary peritonitis. As the biliary system is then collapsed, treatment of this complication by percutaneous reinsertion of a second catheter is difficult if the intrahepatic ducts are not dilated and ERCP may not be possible. In this situation bile will continue to leak into the peritoneum and laparotomy may be required.
However, external drainage is sometimes done when the stricture is difficult to stent.

Discuss the complications of PTC?
Sepsis, haemorrhage, Pancreatitis, peritonitis


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