Background
Over the past few decades, biliary interventions have evolved a great deal. Opacification of the biliary system was first reported in 1921 with direct puncture of the gallbladder. Subsequent reports described direct percutaneous biliary puncture. The technique was revolutionized in 1960s with the introduction of fine-gauge (22- to 23-gauge) needles.
During the 1970s, percutaneous biliary drainage (PBD) for obstructive jaundice and percutaneous treatment of stone disease was introduced. Percutaneous cholecystostomy was first described in the 1980s. With the advent of metallic and plastic internal stents, further applications in the treatment of biliary diseases were developed.
Current percutaneous biliary interventions include percutaneous transhepatic cholangiography (PTC) [1] and biliary drainage to manage benign [2, 3, 4] and malignant obstruction and percutaneous cholecystostomy. [5] Percutaneous treatment of biliary stone disease with or without choledochoscopy is still performed in selected cases. Other applications include cholangioplasty for biliary strictures, biopsy of the biliary duct, and management of complications from laparoscopic cholecystectomy and liver transplantation. [6, 7, 8]
Common causes of benign biliary obstruction include bile duct stones, strictures, sclerosing cholangitis, iatrogenic conditions, inflammatory processes (eg, pancreatitis), and infections (eg, HIV infection, parasitic cholangitis, and recurrent pyogenic cholangitis). Common malignant causes of biliary obstruction include pancreatic carcinoma, cholangiocarcinoma, and metastatic disease. Other causes of biliary obstruction include Caroli disease, Mirizzi syndrome, retroperitoneal fibrosis, ampullary carcinoma, and gallbladder carcinoma.
Standards of practice for PTC have been published by the Cardiovascular and Interventional Radiological Society of Europe (CIRSE). [9]
This article outlines the procedure for percutaneous cholangiography. For descriptions of other biliary interventions, see Percutaneous Cholecystostomy, Percutaneous Biliary Drainage, and Biliary Stenting.
Indications
PTC is indicated for the evaluation of biliary anatomy in the presence of biliary obstruction (eg, after liver transplantation [8] ) when endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful.
In patients with a history of anatomy-altering surgical procedures, however, PTC might be the preferred procedure because ERCP in these settings may require specialized equipment and expertise that may not be universally available. Such procedures include the Billroth II procedure, Roux-en-Y gastric bypass surgery, and the Whipple procedure, to name a few. PTC may be preferable to ERCP for pathologic diagnosis of hilar biliary strictures. [10]
PTC is indicated if there is an inaccessible papilla (eg, in ampullary carcinoma or duodenal obstruction from malignancy). Other indications for PTC include the management of postoperative or posttraumatic bile leakage.
Contraindications
Of the two procedures used to evaluate the biliary anatomy, ERCP and PTC, ERCP is the first test of choice. PTC is more invasive and painful than ERCP, mainly because the PTC procedure involves puncturing the liver capsule. It also poses the risks of hemoperitoneum and bile peritonitis.
PTC is now usually reserved for patients in whom ERCP is unsuccessful when the biliary system cannot be cannulated or when the obstructing lesion prevents contrast material from opacifying the cephalic portions of the biliary system.
Technical Considerations
Procedural planning
Initial clinical evaluation of a patient with jaundice and biliary tract disease should include history taking, physical examination, and pertinent laboratory tests. After the initial workup, radiologic examinations are required to determine the cause of biliary obstruction. Ultrasonography (US), magnetic resonance imaging (MRI), and computed tomography (CT) are commonly used for this purpose. Cross-sectional imaging provides information about the pattern of biliary dilatation and the level of obstruction, and it can potentially reveal the cause. [11]
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Percutaneous cholangiography. Cholangiogram shows opacification of biliary system. Overfilling of biliary system should be avoided.
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Percutaneous cholangiography. Initial path of needle (superior) is at too acute an angle and would have caused difficulty in subsequent catheter placement for percutaneous biliary drainage if continued. Therefore, second puncture (inferior) is performed.
