Percutaneous transhepatic cholangiography

Percutaneous transhepatic cholangiography (PTC) is a radiographic technique employed in the visualization of the biliary tree and can be used as the first step in a number of percutaneous biliary interventions (e.g. percutaneous transhepatic biliary stent placement)

Indications

Purely diagnostic percutaneous transhepatic cholangiography is performed when other less invasive methods of imaging the biliary tree (e.g. MRCP, ERCP, CT IVC) have proven unsatisfactory. Indications include:

• failed ERCP / ERCP not feasible (e.g. patients with gastrojejunostomy)

• biliary system delineation in presence of intra- and extrahepatic biliary calculi

• to identify an obstructive cause of jaundice, and differentiate from medically treatable cause

• anatomic evaluation of complications of ERCP

• delineating bile leaks

• percutaneous biliary stent placement

• postoperative stricture dilatation

• stone removal

Contraindications

• bleeding diathesis

• gross ascites

• biliary tract sepsis

• irreversible coagulopathy

• clopidogrel therapy and unable to hold it

• aspirin use is a relative contraindication

Procedure

Preprocedural evaluation

Before beginning the procedure one must evaluate all the available imaging data of the patient and understand the correct indication for this invasive procedure. Routine investigations that need to be looked at are liver function tests, baseline blood investigations like full blood count, coagulation profile (prothrombin time, PTT, INR, and platelet count); if any of these tests are abnormal corrective measures should be taken before the procedure.

Positioning/room set up

Usually, the procedure is done under local anesthesia with or without sedation (depending upon the patient's cooperation). If the PTC is the first step in a likely painful or time consuming percutaneous biliary intervention, then many centers would prefer to have the patient anaesthetized.

An IV cannula should be placed to maintain vascular access throughout the procedure. Preprocedural broad-spectrum antibiotics are usually administered via an intravenous route.

Routine skin preparation and draping should be performed, exposing a large area overlying the liver, such that a number of trajectories can be employed if need be.

Equipment

• routine trolley pack

• Chiba needle (22G, 15 cm long)

• connecting tube

• water-soluble iodinated contrast medium

Technique

The needle entry point is usually planned by using ultrasound guidance (increasingly used worldwide). A direct fluoroscopic approach was described initially and is still commonly used. A long two-part needle (approximately 15 cm) 22 G is inserted under ultrasound guidance into one of the peripheral ducts; after removing the needle stylet one can observe bile reflux at the needle hub or inject a small amount of contrast to confirm duct puncture on fluoroscopy. Once a satisfactory position of the needle is confirmed, an adequate amount of contrast material is injected and various projections of the biliary tree are obtained to evaluate the obstructive pathology. Images are taken in PA, RAO and LAO views,

Postprocedural care

Provided all has gone well, other than routine cardiovascular observations, no specific post-procedural care is required.

Complications

• bile leakage and biliary peritonitis

• bleeding

• cholangitis

See also

• biliary stricture

• primary sclerosing cholangitis

• primary biliary cholangitis

• cholangiocarcinoma

• periampullary carcinoma