Preprocedural Planning
The workup before percutaneous transhepatic cholangiography (PTC) should include a review of the imaging studies. Pertinent laboratory results are checked, including coagulation parameters, prothrombin time (PT), and activated partial thromboplastin time (aPTT). The hematocrit value, white blood cell (WBC) count, platelet count, and liver function results are obtained.
Antibiotics are routinely administered before the procedure. Antibiotics are necessary because bacteremia and sepsis can develop during the procedure. Roughly one third of patients with malignant obstruction and two thirds of patients with benign obstruction have infected bile. The antibiotics should cover both gram-negative and gram-positive bacteria.
Escherichia coli is the organism most commonly involved; enterococci, Klebsiella species, and viridans streptococci are other common organisms. Penicillins, cephalosporins, and vancomycin are commonly used. In patients with a history of allergic reactions to penicillins and cephalosporins, ciprofloxacin and vancomycin can be used.
Patient Preparation
Position the patient supine, and perform sterile preparation and draping. After the patient is positioned and draped, intravenous (IV) sedatives are given.
The skin-puncture site is anesthetized with a local anesthetic (2% lidocaine), and conscious sedation is needed for adequate pain control. This is achieved by using IV midazolam and fentanyl. An intercostal nerve block can also be used if pain control is inadequate.
Epidural anesthesia and pleural block are options that can be used for especially painful and lengthy procedures (eg, when a drainage procedure or intervention is being performed). General anesthesia may be needed in selected cases.
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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.
