Percutaneous Transhepatic Cholangiography

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.

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.

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.

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]

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.

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.

In most cases, percutaneous transhepatic cholangiography (PTC) can be performed via the right midaxillary approach, though a subxiphoid approach is occasionally needed. Some patients (eg, those with a cholangiocarcinoma involving the hilum and central right and left hepatic ducts) may require bilateral access.

The skin-puncture site is selected by observing the right costophrenic sulcus during deep inspiration. The access point is generally in the midaxillary line in an intercostal space caudal to the costophrenic sulcus. The skin and subcutaneous tissues are anesthetized with local anesthetic.

A 21- or 22-gauge needle is then advanced into the liver under fluoroscopic guidance by aiming for the 12th thoracic vertebral body. After the inner stylet is withdrawn, contrast material is injected while the needle is retracted.

A study by Ignee et al suggested that extravascular contrast-enhanced ultrasonography (CEUS) may be a good alternative to fluoroscopy for guiding PTC and drainage.[12]  Other studies have also supported the use of CEUS in PTC.[13]

Specific flow patterns of the contrast agent are noted. The vessels show opacification that disappears rapidly, whereas the bile ducts show slow opacification. The portal vein blood flows toward the periphery of the liver, filling the portal vein branches and sinusoids, whereas the hepatic vein blood flows toward the right atrium without filling its branches. The bile duct filling moves slowly toward the hilum into the extrahepatic duct. Occasionally, one may see filling of lymphatic channels, which are small in diameter and multiple.

After successful puncture of a bile duct, contrast medium is injected, and cholangiography is performed to delineate the biliary anatomy (see the image below).

If the contrast medium flows freely through the bile duct into the duodenum, films are taken with additional injections of contrast medium in the multiple projections. If the bile duct is dilated secondary to biliary obstruction, an introducer is inserted for biliary decompression before a diagnostic cholangiogram and placement of a drainage catheter. Overdistention of an obstructed biliary system can cause bacteremia and sepsis.

If the needle enters a bile duct in a position unsuitable for subsequent catheterization, a second needle can be used to puncture the opacified ducts (see the image below). The left hepatic ducts are anterior in relation to the right lobe ducts and therefore may not fill with the patient in the supine position, because the contrast flows to the more posterior and dependent right ducts. If not already seen, the left hepatic ducts can be opacified by having the patient roll to the left.

After the biliary system is delineated and images are obtained, the needle can be withdrawn if no further intervention is necessary.

The success rate for PTC is reported to be more than 95% in a dilated biliary system and 67-80% in a nondilated system. Additional needle passes increase the success rate.

Alternatives to PTC

Diagnostic PTC has largely been replaced by noninvasive diagnostic modalities such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic US (EUS). With the advent of techniques such as EUS-guided biliary drainage that permits ERCP rendezvous or antegrade stenting to be performed,[14] the demand for PTC has been decreasing. However, PTC remains a very useful rescue therapy for biliary pathologies when other modalities fail.

Complications of PTC include the following:

• Sepsis (for which poor adherence to recommended antibiotic regimens may be a significant contributing factor ^[15] )
• Peritonitis
• Hemorrhage
• Pneumothorax

Pneumothorax is rare and is associated with a right-side approach. To minimize this risk, perform fluoroscopic examination of the right costophrenic sulcus during deep inspiration to evaluate diaphragmatic excursion, and choose a puncture site caudal to the sulcus.