DRAINAGE

PTCD

Introduction

Last updated: apr 5, 2023

Also known as Percutaneous Transhepatic Biliary Drainage (PTBD), it is the gold standard for patients in whom Endoscopic Retrograde CholangioPancreatography (ERCP) is unsuccessful.

Bismuth classification
 

Anatomy

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Indications

  • Obstruction – benign, malignant, or infection-related, or symptoms due to obstruction (nausea, pain, itching)
  • Leakage – for example, post-operative

Metal stents

  • Indicated for Distal Malignant Biliary Obstruction (DMBO)
  • More than 50% drainage is required for "long-term survival"
  • No significant difference exists between bare-metal and covered stents. 1

 

Contra indications

Absolute

  • Increased risk of bleeding
  • Sepsis
  • Large volume of ascites
  • Multilevel obstruction

Relative

 

Pre procedural

  • Antibiotics
  • Sedation team

 

Materials

Essentials

  • Sedation
  • Ultrasound
  • NEF set
  • 8F sheath, 25 cm
  • Stiff Terumo guidewire
  • PIER catheter
  • 5 mm PTA balloon
  • Biliary drain

Non-Essentials

 

Positioning the patient

  • Prone
  • Right arm raised

 

The procedure in steps

  • Time out
  • Positioning of the patient
  • Determining puncture site using ultrasound
  • Cleansing with chlorhexidine and sterile draping
  • Ultrasound-guided puncture (NEF set) of a peripheral bile duct
  • Removal of the mandrin and injection into the biliary system
  • Insertion of the guidewire (NEF set)
  • Over-the-wire placement of the sheath (NEF set)
  • Exchange for a stiff wire
  • Insertion of an 8F 25 cm sheath
  • Crossing the stenosis/obstruction with a PIER catheter
  • Position confirmation in the intestine
  • Over-the-wire 5 mm pre-dilatation
  • Placement of the internal biliary drain
  • External fixation and capping
  • Sign out

 

Tips and tricks

Punctie

Een kleine scherpe bocht aan het uiteinde van de naald maakt deze stuurbaar, zodat het herpositioneren van de naald tot een minimum gereduceerd kan worden.

Geen dilatie

In cases of a non-dilated system, use the Double Wall Puncture (DWP) technique. The puncture should be made peripherally at the portal branches, after which the stylet is removed. Connect a flexible catheter to a 50/50 solution of NaCl and contrast, injecting while withdrawing. Ensure that the biliary ducts are adequately filled before introducing the wire.

If this approach is unsuccessful, consider gaining more central access to fill the biliary ducts. Subsequently, more peripheral access can be achieved through fluoroscopic guidance. Preferably, puncture with a second needle while keeping the first in position to allow for "replenishment." A small sharp bend at the needle's tip can enhance maneuverability, minimizing the need for repositioning.

Geen connectie met duodenum

If access to the duodenum is not successful in the first session, it can be beneficial to give the system some rest for a few days before attempting again.

Veel ascites

If drainage is deemed necessary in cases of significant ascites, perform complete drainage. When removing the sheath/drain, fill the tract with Spongostan or coils.

 

Complications

  • Cholangitis 2-5%
  • Haemorrhage 0-5%
  • Peritonitis 3%
  • Bile leakage 1-3%%
  • Fistula between bile and bloodvessel 2%
  • Pseudoaneurysm 1-2%
  • Pneumothorax 1%
  • Death 2

The risk of a haemorrhage is significantly increased in a non-dilated system

 

Report

 

Literature

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