PTBD (Percutaneus trans-hepatic biliary drainage) PPT,PDF PK

This presentation include biliary anatomy ,indication, contraindication post op care of percutaneus transhepatic biliary drainage with important technique. and advantage and disadvantage of different technique. This is important for radiologist, radiographers, intervention radiologist radiology resident. Thanks

1. PTCD/PTBD Pradeep Kumar Radiology resident

2. PTCD/ P TBD Percutaneous Transhepatic biliary drainage is a therapeutic procedure that involves sterile cannulation of periphery biliary radicle after percutaneous puncture followed by imaging guide wires and catheter manipulation. Placement of External or Internal Stent or drainage tube completes the procedure

3. Bilia r y T r e e An a t o m y

4. www.ijri.org/articles/2016/26/1

5. Methods of Imaging Biliary Tract ➢ Indirect Imaging Involves Non Invasive Technique Ultrasound Plain Film CT MRCP Oral, IV Cholecystography Cholescintigraphy ➢ Direct Imaging Involves Invasive Radiologic Procedure ERCP Operative and T tube Cholangiogram PTC

6. E R CP P T C T-TUBE CHOLANGIOGRAM

7. Contraindication Coagulation Problem ( Platelet count< 100,000 mm3 and INR greater than 1.5 . Biliary Infection. Hypersensitivity to contrast medium Severe heart disease and respiratory disease Poor General condition of patient Extreme Jaundice. Ascites. Anemic Immediately after an hydatid cyst removal . Hydatid disease. Uncooperative patient.

8. Patient Preparation BLOOD TEST : Hemoglobin, Bilirubin, Sugar, Cholesterol, Haemogram , Prothrombin time & Platelets, HBsAg, HCV, HIV test, Blood grouping report. USG/CT /MRI report (information about level of obstruction & assessment of the tumor resectability & planning appropriate approach to biliary decompression). ECG, CXR report.

9. Prophylactic antibiotics : Broad spectrum antibiotics from 24 hours before procedure & for 3 days afterwards. NPO for at least 4-6 hours before procedure. Sedation/Analgesics : as required. Open IV line in a arm to administer medications during the procedure. May continue to take medication : e.g. Heart diseases, HTN, DM with a little of water.

10. informed consent form that gives patient/guardian permission for the procedures. Asked allergic to any medications, especially antibiotics , iodine or radiological contrast media. ECG leads may be placed on chest & a BP cuff placed on arm to monitor heart rate & blood pressure during the procedure. Recording of Oxygen level & vitals.

11. Premedication Hyoscine N butyl bromide 20 mg IM. Diazepam 10 mg I/V. Continue broad spectrum antibiotics

12. Contrast Medium LOCM 150mg I ml, 20-60 ml. Sedative: Midazolam and Analgesic: Lidnocane 3%

13. Equipment Ultrasound Machine, Fluroscopic Unit with spot film device and tilting table. Chiba needle ( flexible 18 -22 G, 15-20 cm long, with stainless steel needle. 21F , 15cm long with with outer and inner diameter 0.7 and 0.5 mm respectively). Betadine, cotton swabs, sterile gloves, forceps . Local anaesthetic injection: Lignocaine 2%. Guide wires, Dilators, Metallic stents. Catheters: Exterior drainage catheters Internal drainage catheters Balloon dilatation catheters

14. 20 PTCD: Equipments Required Chiba needles Drainage catheter

15. Equipment Required Vascular Ascess Sheath and dilators

16. J tipped Stiff Guidewire

17. Must Required Duct must have been dilated

18. Preliminary Imaging US to confirm position of liver and dilated ducts.

19. Patient Position/Location ○ Right/left/bilateral drainage may be performed ○ Right-sided access generally preferred – Straighter course for wire/catheter manipulation – May have higher radiation exposure to operators’ hands with left-sided access ○ For PTBD, appropriate lobe to drain depends on – Site of obstruction □ Right or left drainage usually sufficient for distal common duct obstruction □ If confluence obstruction, may perform bilateral drainage or unilateral drainage of larger lobe

20. Right PTC/PTBD access – Patient supine on fluoroscopy table – Right mid-axillary line approach – 9th to 11th intercostal space □ Ask patient to take deep breath; prefer access below lung margin – Advance needle, initially parallel to table, toward T12 vertebral body □ Alternatively, may access dilated duct directly using ultrasound guidance, if visible

21. Left PTC/PTBD access ○ Patient supine on fluoroscopy table – Subxiphoid or subcostal approach – Visualize dilated duct with ultrasound □ If accessible, segment II duct preferred: Forms less acute angle with left main duct □ Segment III duct courses vertically; may be more accessible than segment II duct

22. Technique Obtain IV access: give antibiotics, sedation and analgesia. patient is placed in a supine position, and sterile preparation and draping are performed. Puncture the duct: aim for a point where the duct is large enough to accommodate the catheters and drains that you plan to use, but fewer complications the more peripherally you puncture Through usg guidance chiba needle is inserted into dilated duct. Confirm intraduct position: free backflow of bile indicates that you are in the duct; make sure you put a decent length of the 0.018-inch wire into the duct. Stellate from the Chiba needle is removed and once bile observed, a J tipped stiff guidewire ( 150cm long. 0.035”) is inserted upto the area it could reach.

23. Technique Exchange the 0.018-inch wire for the 0.035-inch J wire: using the coaxial set. Dilate a tract into the duct: Use 5F or 6F dilators, depending on the size of catheter you intend to use. Introduce the catheter you hope to use to cross the stricture; most operators use either a Cobra or a biliary manipulation catheter. Take a sample of bile: for microbiology ± cytology. Cross the stricture: this is often harder than it sounds. We usually start with the curved hydrophilic wire. The process is similar to crossing a stricture or occlusion in a blood vessel

24. Technique Confirm intraluminal position: always ensure that you are either in the distal bile duct or through to the duodenum. Exchange for the Amplatz super-stiff wire: aim to have the wire into the 3rd part of the duodenum. Confirm free drainage: make sure you do this before you attach the catheter! Fix the drain catheter to the skin: there are many options for this; so either use a suture or a proprietary skin fixation device.

25. Contrast is injected to opacify the biliary system

26. Technique Two approaches are used: Right lateral (mid-axillary) approach. Anterior, Subcostal or Left sided subxiphoid approach.

27. Features Right-sided puncture Left-sided puncture 1 Patient comfort Painful , restricted patient movement. Less painful, Increased patient comfort. 2 Technical ease of puncture Diffcult Easy 3 Associated risk Pleural transgression, injury to intercostal neurovascular bundle - 4 Radiation exposure Less radiation to operator Higher radiation exposure to operator’s hands 5 Preferred duct Anterior sectoral duct Segment three duct- antero-inferior to segment two duct. 6 Puncture site Below 10th rib at mid-axillary line Subxiphoid or substernal.

28. Right lateral (mid-axillary) approach

29. Anterior, Subcostal or Left Sided Subxiphoid Approach ADVANTAGES Less complications than right puncture. Larger & horizontal course with constant anatomy of left biliary duct makes target easier. No risk of pleural puncture. Straight & short course through the liver makes easier placement of the guide-wires, stents & balloons.

30. Anterior, Subcostal or Left Sided Subxiphoid Approach ADVANTAGES Less pain with movement or breathing as external drainage catheters do not pass between the ribs. Easier to manage, cleaning & dressing the catheter by the patient- so less likely to be dislodged. No diaphragmatic puncture therefore no irritation unlike right approach.

31. Anterior, Subcostal or Left Sided Subxiphoid Approach DISADVANTAGES The major entry site (Lt. Medial segment duct) curvature can make difficult to pass large catheters, dilators. Increased radiation exposure to the operator’s hands. Chance of false localization of level of obstruction. Opacification of left anterior duct can be difficult in supine position. Shorter tract: less compressing effect, greater chance of bleed or bile leakage .

32. Percutaneous Transhepatic Cholangiography and Drainage (PTCD) PTBD: External Drainage This is achieved following Trashepatic cannulation of the biliary tree. Used to reduce operative morbidity in jaundiced patient.

33. Various Biliary Drain catheter are used . For External drainage, suitable catheter can be inserted over the wire after the sheath is withdrawn. Commonly used catheters have a retaining pigtail loop with holes. The internal fixation is achieved by using a loop-retaining suture. Succesful Biliary drainage is defined as placement of tube or stent to provide continuos drainage of bile.

34. PTBD: Internal Drainage Achieved following transhepatic or endoscopic cannulation of biliary tree. Preferable because of the complication of long term transhepatic catheterization. Insertion of catheter or bypass stent in the bile duct draining either externally or long time for internally to relieve pressure remains in place for further few days until the icterus & clinical features subsided.

35. For internal drainage or stent insertion the wire and 10 f Flixible Biliary drainage catheter must be passed through the stricture into the duodenum. A varieties of catheter wires are needed to pass the barrier.

36. Major Complication Sepsis Haemorrhage Localised Inflammatory/Infectious Abscess, peritonitis,cholecystitis, Pancreatitis Dislodgement of catheter Blockage of Cathetar Perforation of bile duct above the stricture on passage of guidewire Death Pleural effusion, Pneumothorax in rt approach

37. After Care Bed Rest Pulse and Blood pressure measurement half hourly for 6 hrs. Antibiotic Prophylaxis for atleast 3 days. An External draining catheter should be flushed through with normal saline and exchanged at every three months.

38. Advice for rest: right lateral to give compression to punctured site. Close observation for 24 hours. Vital signs recorded half hourly for 12- 24 hours. Checking of punctured site for bleeding, leakage of bile, intra-peritoneal haemorrhage & any sign of peritonitis at the same time.

39. The bile in the collection bag also checked for colour , amount,& presence of blood, Several doses of antibiotic medication through IV to prevent infection. Continue antibiotics for further few days.

40. If the patient is discharged with a catheter in place , teach how to : care for the catheter at home. change the bandage around the catheter. do daily irrigations through the tube (flushing the catheter with sterile water). showering or bathing safely .

41. THANK YOU

42. Q. Identify ?

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45. Q. Which of the following is false about klatskin tumour? a term that was traditionally given to a hilar cholangiocarcinoma, occurring at the bifurcation of the common hepatic duct. PTC is gold std to diagnosis of hilar choalngocarcinoma . In Usg increased echogenicity relative to surrounding liver is most common findings. The Bismuth- Corlette system is one classification.

46. Q. All of the following are true except? Rt sided approach is painful than left sided approach. Left sided approach having less radiation exposure to operator hand than right approach. c) Rt sided approach puncture site below 10th rib at mid-axillary line. d) In rt sided approach more injury to intercostal neurovascular bundle than left sided approach.