Percutaneous Transhepatic Biliary Drainage (PTBD)

Indications

Contraindications

Relevant Anatomy

Biliary Tree and Obstruction Level

The right hepatic duct and left hepatic duct join at the hilar confluence to form the common hepatic duct (CHD), which receives the cystic duct and becomes the common bile duct (CBD), draining through the ampulla of Vater into the duodenum. For pancreatic head and distal CBD obstruction, either left or right approach can achieve drainage. For hilar obstruction (Klatskin tumor), drainage strategy is guided by the Bismuth classification.

Bismuth Classification for Hilar Tumors

Type I: Obstruction below the CHD confluence — unilateral drainage is usually sufficient. Type II: Obstruction at the confluence — attempt to cross both ducts; unilateral drainage may be adequate if crossing is achieved. Type IIIa/IIIb: Extends into right (IIIa) or left (IIIb) hepatic duct — ipsilateral drainage targets the more involved side; contralateral drainage if technically feasible. Type IV: Bilobar involvement — bilateral drainage rarely provides full benefit; prioritize drainage of the functional liver volume rather than achieving complete bilateral drainage.

Left vs. Right Hepatic Approach

The left hepatic approach (subxiphoid or subcostal, targeting segment II/III ducts) is preferred in most cases — the segment II/III ducts are peripheral and consistently accessible, and the more horizontal trajectory provides better alignment to cross the obstruction into the duodenum. Critically, the left approach does not traverse the intercostal space, substantially reducing pneumothorax risk. The right hepatic approach (8th–10th intercostal space, anterior axillary line) is used for isolated right-system disease — requires careful rib-level confirmation to avoid the pleural space.

Pre-Procedure Checklist

Imaging Review

• MRCP or CT to characterize obstruction level — hilar vs. pancreatic head vs. intrahepatic; identify the Bismuth classification for hilar tumors
• Plan approach: left (preferred for most) vs. right vs. bilateral
• Assess for massive ascites — reduces safe window and increases peritoneal leak risk

Labs

• CBC, comprehensive metabolic panel (bilirubin, LFTs), coagulation panel
• SIR Category 3: target INR <1.5, platelets >50,000; correct with FFP or vitamin K if needed
• Baseline bilirubin documents severity and is the primary metric for response assessment at 48–72 hours

Consent Considerations

Discuss: sepsis/cholangitis (2–10%), hemorrhage (~1–3% major; pseudoaneurysm), bile peritonitis, hemobilia, pleural complications (right-sided approach), drain malposition or dislodgement, failure to achieve internal crossing (external-only drainage may be the result), procedure-related mortality (0.1–0.8%), and the need for long-term drain management.

Procedure Overview

The following is a high-level summary. Full step-by-step technique, wire manipulation, and drain conversion are available in RadCall Pro.

1. Approach selection — left hepatic approach (subxiphoid, segment II/III) for most cases; right hepatic approach (intercostal) for isolated right-system disease
2. Biliary duct access — advance access needle into a peripheral bile duct under fluoroscopic guidance; confirm biliary position by slow central contrast column (distinguish from portal vein — rapid dilution; hepatic artery — pulsatile flow)
3. Cholangiogram — inject dilute contrast to delineate biliary anatomy, confirm obstruction level, and plan crossing approach; avoid overdistension (increases sepsis risk)
4. Exchange to working system — advance wire and exchange to working catheter over the access; perform diagnostic cholangiogram to characterize obstruction
5. Crossing the obstruction — attempt to advance wire and catheter across the obstruction into the duodenum; successful crossing enables internal-external drainage; if crossing is not achievable, external-only drainage is placed
6. Drain placement — place internal-external biliary drainage catheter (preferred) with side holes above and below the obstruction; or external-only drain if crossing not achieved; confirm catheter position fluoroscopically
7. Secure and connect — suture catheter to skin; connect to drainage bag; document bilirubin for response tracking at 48–72 hours

Complications

Post-Procedure Care

Monitoring

• Vital signs every 1 hour for 4 hours; temperature monitoring for cholangitis
• Drain output documentation — bile output should begin immediately; note character (bile-colored, bloody, or purulent)
• Bilirubin check at 48–72 hours — should begin to fall with successful drainage; failure to improve warrants reassessment of drain position and patency
• Extend antibiotics 24–48 hours post-procedure for all patients; longer courses for those with pre-existing cholangitis

Drain Management

• Routine drain exchange every 3 months for long-term malignant obstruction management
• Cholangiogram at 48–72 hours to confirm drain position and assess for conversion to internal stent placement when appropriate
• Patient and caregiver education for external drain care; home nursing if needed

When to Escalate

• Post-procedure sepsis or cholangitis — escalate antibiotics; confirm drain is patent and draining freely; urgent blood cultures; consider IR for drain check and possible upsizing or repositioning
• Hemobilia or significant hemorrhage — CT for characterization; urgent angiography and embolization for active arterial source (hepatic artery pseudoaneurysm is most common etiology)
• Bilirubin not improving at 72 hours — assess drain position and patency with cholangiogram; consider repositioning or additional drainage of a different segment
• Bilateral drainage required but first approach fails — contralateral approach for Bismuth III–IV or when first approach does not drain adequate functional liver volume

References

• Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg Gynecol Obstet. 1975;140(2):170–178.
• Covey AM, Brown KT. Percutaneous transhepatic biliary drainage. Tech Vasc Interv Radiol. 2008;11(1):14–20.
• SIR Quality Improvement Guidelines for Percutaneous Biliary Drainage.