Percutaneous transhepatic cholangiography

Percutaneous transhepatic cholangiography

Introduction

A radiological technique called Percutaneous transhepatic cholangiography, also known as percutaneous hepatic cholangiogram (PTHC), is used to see the biliary tract’s anatomy. After injecting a contrast agent into a liver bile duct, X-rays are obtained. When endoscopic retrograde cholangiopancreatography has failed, it provides access to the biliary tree. First documented in 1937, the process gained popularity in 1952.

Percutaneous transhepatic cholangiography

Applications

This procedure can be used to remove stones, drain bile or infected bile to treat obstructive jaundice, place a stent to dilate a stricture in the biliary system, and perform a rendezvous technique at the major duodenal papilla, where the guidewire from the common bile duct (CBD) meets with the duodenoscope (which comes from the oesophagus into the stomach and then the duodenum). Using the rendezvous technique, a small blade is slid over the guidewire into the CBD and a specific bile duct in the biliary system is operated on. The guidewire is then pulled into the duodenoscope. A common procedure used to guide biliary system therapy is PTHC. It is rarely used exclusively for diagnostic purposes.
Hydatid cysts that are not ruptured or are not complicated can also be drained using PTHC. In rare instances, PTHC is utilized for hydatid cyst rupture drainage.

Percutaneous transhepatic cholangiography

Restrictions

Among the contraindications are prothrombin time prolonged more than 2 seconds longer than the control and increased bleeding tendency where platelets less than 100×109/litre. Additionally, this procedure is not recommended in cases of biliary tract sepsis, with the exception of draining the infected bile to control the infection.

Percutaneous transhepatic cholangiography

Method

In this procedure, 20 to 60 milliliters of low osmolar contrast medium at a concentration of 150 mg/ml are used. Four hours prior to the procedure, the person getting the procedure must fast. In addition, antibiotic prophylaxis, such as 500–750 mg of ciprofloxacin, can be administered to avoid infection during the procedure. Vital sign monitoring and sedation (to lessen the subject’s agitation and irritation during the procedure) should be arranged.
Bedside ultrasonography is performed prior to the procedure to verify the location of the liver’s dilated bile ducts. Next, the puncture site is labeled. Between the anterior and mid-axillary lines in the intercostal spaces are the right liver’s bile ducts. On the epigastric area, the bile ducts in the left lobe of the liver are situated to the left of the xiphisternum.
The likelihood of success is correlated with the degree of biliary tract dilatation (larger dilatation means needle is easier to find its way into the biliary tract) and total number of attempts made, but the number of attempts made to pass the Chiba needle into the biliary tract does not affect the rate of complications.
It is best to avoid injecting too much contrast media into the liver. Contrast medium will opacify the liver’s lymphatics when there is an overabundance of injection into the organ. When a contrast medium is injected into a vein or artery, blood flow causes the contrast to spread out quickly.
Primary choloangiography, or perioperative choloangiography, is the term for choliography performed during a biliary drainage intervention; secondary choliography is the term used for choliography performed later in the same drain.

Percutaneous transhepatic cholangiography

Difficulties

In comparison to endoscopic biliary drainage, percutaneous transhepatic cholangiography may increase the risk of bleeding, dislocation of the tube, and metastases. When compared to endoscopic biliary drainage, it has a lower rate of cholangitis and pancreatitis. This is likely due to the latter’s increased risk of incomplete bile drainage or unintentional papilla resection, which can result in the backflow of contaminated bile from the duodenum into the biliary system.

Percutaneous transhepatic cholangiography

Biliary drainage via percutaneous transhepatic means

When endoscopic retrograde biliary drainage (ERBD) fails to clear biliary obstructions caused by hepatocellular carcinoma, percutaneous transhepatic biliary drainage (PTBD) is frequently carried out. The first line of treatment is ERBD due to its low risk of bleeding. Depending on the clinical circumstances of the patient and the physician’s preference, both ERBD and PTBD can be performed for biliary obstruction at the hilum (meeting point of right and hepatic hepatic ducts).

Percutaneous transhepatic cholangiography

The transhepatic percutaneous method

When papillotomy (cutting through the major duodenal papilla to relieve stenosis), endoscopic retrograde cholangiopancreatography (ERCP), or stone removal fail, this procedure is indicated. The Billroth II stomach resection and other major modifications to the stomach and small intestine, as well as conditions like intradiverticular papilla (duodenal papilla inside a duodenal outpouching), stenosis of the duodenal papilla, stone within the distal CBD, stenosis of the ampulla of Vater, stone in the peripheral bile duct, or stone larger than 15 mm, are also indications for this procedure.
On a cholangiogram performed on a T-tube previously inserted into CBD, biliary calculi are visible. This occurs in 3 percent of cases after biliary stone surgery. Acute pancreatitis, tortuous T tubes in tissues, T-tubes that are too small (less than 12 French in size), and the presence of another drain connected to the T-tube tract all make this procedure contraindicated.To lessen oedema in the biliary ducts and the sphincter of Oddi oedema, PTBD is performed one to two weeks prior to the procedure.

Percutaneous transhepatic cholangiography

Trans T-tube method

On the tenth day following surgery, post-operative T-tube cholangiography is carried out. A volume of 20 to 30 ml of either high-or low-osmolar contrast media with a concentration of 150 mg/ml is injected through the T-tube to ascertain whether there is a leak from the biliary tract or if there are any remaining stones within the biliary system.
Burhene technique is another name for the trans T-tube method of stone extraction. After an abdominal operation, the T-tube tract matures and fibrous tissue forms at its walls to support and maintain its open state. This procedure is performed five to eight weeks after the initial abdominal operation. After that, the T-tube is advanced through with guidewire and removed. Subsequently, a cholangiogram is conducted with a catheter placed over the guidewire to visualize the biliary tract’s anatomy and the locations of the stones.

References

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