Overview of Percutaneous Transhepatic Cholangiography
Percutaneous transhepatic cholangiography (PTC), first introduced in 1937 and popularized in the 1950s, is a medical procedure used for diagnosis and treatment. It involves a needle being inserted into the bile ducts (a network of tubes where bile flows in the liver) with the help of a thin tube or catheter for draining bile, which is a digestive juice produced by the liver. This process is often guided by fluoroscopy or ultrasound, which are types of imaging techniques that allow the doctor to see the inside of your body on a screen.
One of the main uses of PTC is in the management of a condition known as obstructive jaundice which is associated with certain types of cancer. This condition causes a yellowing of the skin and eyes because of high levels of a substance known as bilirubin in the blood. PTC helps lower bilirubin levels and improve liver function, and enables other types of treatments such as drainage and diagnosis.
Sometimes, if there is a suspicion of a blockage in the bile ducts due to cancer, only using imaging techniques may not give accurate results. In these cases, PTC helps by allowing doctors to take samples for further testing using techniques like fine needle aspiration, brush cytology, and forceps biopsy, which were commonly employed during this procedure since the 1980s.
Another process known as percutaneous transhepatic biliary drainage (PTBD) via PTC, which was introduced in 1981, is a safe and effective method for draining bile. This is especially helpful for patients with multiple health conditions who may not be able to tolerate surgery, and for those who are not suitable candidates for a procedure known as endoscopic retrograde cholangiopancreatography (ERCP). However, PTBD primarily focuses on easing symptoms and does not cure the underlying condition. The Cardiovascular and Interventional Radiological Society of Europe (CIRSE) even provides guidelines for how to perform this procedure.
Anatomy and Physiology of Percutaneous Transhepatic Cholangiography
The process of PTC, or Percutaneous Transhepatic Cholangiography, which is a procedure doctors use to take images of your liver and bile ducts, needs a thorough knowledge of the body’s biliary system. This system is broken down into two parts: extrahepatic, which is outside the liver, and intrahepatic, which is inside the liver.
The extrahepatic system includes a duct called the common hepatic duct, which transports bile, a fluid that helps digestion, from the liver. This duct connects with another one, the cystic duct from the gallbladder, to form the common bile duct. This common bile duct moves down towards a part of our small intestine called the duodenum. Near the duodenum, it might connect with the pancreatic duct and then enter the duodenum. The common bile duct’s flow is controlled by a muscle called the sphincter of Oddi that decides whether to release the bile to the duodenum or keep it in the ducts where it can then flow back into the gallbladder. The gallbladder, in this case, works as a storage house for bile.
Now, the intrahepatic biliary system is a bit more complicated. It is essentially a network of tiny bile ducts within the liver, which starts at the bile canaliculi between liver cells or hepatocytes. These little ducts are usually not visible in typical imaging procedures unless they become abnormally large. The small ducts gradually join together to form larger ones, eventually becoming the right and left hepatic ducts. As you may guess, the right hepatic duct drains bile from the right part of the liver, while the left hepatic duct serves the left part. These two ducts eventually become the common hepatic duct.
About half of us have a single duct servicing the left part of the liver and a single duct formed by the joining of an anterior (front side) and posterior (back side) duct for the right part. However, this configuration can vary with some people having a right anterior segmental branch, responsible for draining segments V and VIII, that directly drains into the common bile duct and a right posterior segmental branch, draining segments VI and VII, that drains somewhere else.
When doctors are doing the PTC procedure, it’s crucial to be aware of any potential anomalies a patient may have, such as abnormal biliary ducts, cystic duct placement, choledochal cysts, diverticula, or an unusual connection between the bile and pancreatic ducts.
Why do People Need Percutaneous Transhepatic Cholangiography
Percutaneous transhepatic cholangiography (PTC) is a useful procedure that helps doctors examine and treat issues in the bile ducts. Let’s understand why it’s used.
Evaluation of obstructive jaundice: Obstructive jaundice is a condition where the skin turns yellow due to a blockage in the bile ducts. With PTC, doctors can figure out the cause of this blockage, which could be due to narrowing of ducts (known as strictures), stones, or tumors.
Biliary drainage: If a patient has obstructive jaundice, a specific type of tube, called a catheter, can be inserted into the bile ducts using PTC to help drain the bile. PTC is particularly useful when other methods like Endoscopic Retrograde Cholangiopancreatography (ERCP) can’t be used, for example, when a patient has an altered anatomy or bile duct obstruction.
PTC is often used in treating patients with a rare liver disease called biliary atresia, who have undergone a surgery called Kasai portoenterostomy and are now experiencing complications, including recurrent cholangitis (inflammation of the bile duct) and biliary stricture.
Treatment of biliary leaks: Sometimes, bile can leak out of the bile ducts, especially after liver surgery or injury. PTC can be used to identify and manage this leakage.
Biliary stenting: With the help of PTC, doctors can place a small tube called a stent into the bile ducts to keep them open and relieve obstruction.
Preoperative assessment: Doctors may perform a PTC before surgery involving the bile ducts. This helps in making an informed decision about the surgery.
Therapeutic interventions: PTC can help doctors to perform various treatments such as removing stones, collecting tissue samples for testing, and widening narrow bile ducts.
Evaluation of biliary anatomy: PTC also gives a detailed image of the bile duct system, which can help in identifying any unusual structures or anomalies present.
Retrieval of foreign bodies: There have been instances where foreign objects such as a wire cage (Dormia basket) stuck in the common bile duct have been successfully removed using PTC.
When a Person Should Avoid Percutaneous Transhepatic Cholangiography
Sometimes, a procedure called PTC may not be suitable for certain individuals due to potential risks and complications. Here are some reasons why PTC might not be a good option:
If ERCP (a procedure which uses a flexible tube to check bile ducts) can be performed. This is often preferred as a first option for certain types of blockages because it’s linked with less complications, better survival rates, and improved quality of life.
If you have a blood disorder or coagulopathy, which could make you bleed more. PTC involves inserting a needle into the liver to access the bile ducts, and this could cause bleeding. If you have a problem with your blood clotting, PTC can be even riskier. It’s recommended that anyone having PTC should have a certain level of blood clotting ability and a particular number of platelets (blood cells that help your blood clot).
If your bile ducts are not expanded. If PTC is performed when the bile ducts are not wide enough, it can be difficult to carry out successfully and may have to be delayed if the ducts might widen after a short time.
If you have unstable health conditions like shock or severe heart problems, PTC might not be safe because of the risks associated with the procedure and the anesthesia.
If you have uncontrolled infections, particularly in the area around the liver or the path that bile travels (also known as the biliary tract), doing a PTC can increase the risk of complications like sepsis or abscesses.
If you’re allergic to contrast material, which is used during PTC to help visualize the bile ducts and to diagnose problems with the biliary tract, you could respond adversely during the procedure.
If you can’t stay still or follow instructions during the procedure, PTC might not be possible.
If your body has certain unique features or abnormalities that could make PTC more difficult or unsafe to do.
If you’re pregnant, there could be risks to your unborn baby because PTC involves some exposure to radiation.
Before deciding to do PTC, all of these factors should be considered by your healthcare team. If you’re not a good candidate for PTC, other diagnostic or treatment options can be explored. Additional considerations which might make PTC less suitable will also be considered during the preparation for the procedure.
Equipment used for Percutaneous Transhepatic Cholangiography
Performing Percutaneous Transhepatic Cholangiography (PTC) is a procedure that requires specialized tools to ensure everything goes smoothly and safely. Here are the key equipment needed:
- Fluoroscopy machine: This machine gives real-time x-ray images that helps your doctor accurately place the needle into the liver and bile ducts during the treatment.
- Local anesthetic medications: These are medicines that numb your skin and the tissues covering your liver, at the point of insertion, that way you don’t experience any discomfort.
- Needles: We use specific types of needles, like Chiba needles or modified Seldinger needles, to prick the skin and reach the bile ducts in the liver.
- Contrast media: This is a special dye that we inject into your bile ducts, so they can be clearly seen on x-ray images. We usually use a type of water-soluble iodinated contrast agents for PTC.
- Syringes and injection devices: These are the tools that help us inject the contrast dye through the needle and into the bile ducts.
- Sterile drapes, gowns, and gloves: These are all part of the practice to keep everything sterile during the procedure. This helps lower the risk of infection.
- Dressing materials: Once the procedure is over, we would use sterile gauze and band-aids to cover the insertion site as a step to prevent any bleeding and infection.
- Monitoring equipment: These tools are used to check your vital signs throughout the procedure.
- Sedation equipment and sedatives (optional): In some situations, depending on your condition and how complex the procedure is, we may use machinery and medications to help you feel more comfortable and relaxed.
- Additional equipment: Sometimes, we may use extra tools like ultrasound machines or guidance devices to assist with needle placement, particularly in instances where the bile ducts are challenging to see with just the fluoroscopy machine.
Who is needed to perform Percutaneous Transhepatic Cholangiography?
Doing a PTC, short for Percutaneous Transhepatic Cholangiography, needs a team of different healthcare professionals to make sure it’s done safely and correctly. This is who is usually involved:
There’s an interventional radiologist, who is a doctor that mainly uses things like x-rays and ultrasound to diagnose or treat diseases. They’re the one who leads the procedure.
There’s also a radiology technologist. They help the radiologist by operating the machines that produce the images. Kind of like when you go for an x-ray, there’s someone who works the machine, right? This is them.
An anesthesiologist or a nurse anesthetist could also be there. They help manage pain during procedures – they’re the ones who can give you medicine to make you sleep or numb an area of your body.
Then, there’s a circulating nurse. They don’t do the actual procedure, but they’re there to assist the team and make sure everything runs smoothly. They can pass tools, help with paperwork, and other important tasks.
Finally, there are support staff like medical assistants or surgical technicians. They’re in the background, helping prepare the room, the machines, and maybe even you for the procedure.
All these people work together to get you the best care possible during a PTC procedure. They each have a role to play and they do it well.
Preparing for Percutaneous Transhepatic Cholangiography
Before a certain medical procedure known as Percutaneous Transhepatic Cholangiography (PTC), doctors take several steps to ensure it’s done safely and successfully. Let’s first explain what PTC is – it’s a technique used to visualize the bile ducts and pinpoint any blockages in them.
To understand the patient’s health and plan the best possible procedure, doctors use special types of imaging. This includes detailed pictures of the body’s inside to understand the layout of the ducts that help digest food, find out where any blockages are, and possibly figure out what’s causing them. These insights help doctors decide the best approach to the procedure – for example, whether to access the bile ducts from the right or left side of the liver.
Doctors might also use a certain type of radiology test, called a hepatobiliary iminodiacetic acid scan. This test helps examine how the liver functions and to define or exclude problems such as a bile duct leak.
When it comes to preventing infections after a PTC, doctors typically agree that all patients should receive antibiotics to fight off certain types of bacteria. This can help lower the chance of severe infections like sepsis, even if there’s no evidence suggesting the intestines might come into contact with the bile ducts. Although some doctors will also give antibiotics for other types of bacteria, based on recommendations from the Society of Interventional Radiology (SIR), this is not always necessary. To decide on the best type and dose of antibiotics, doctors work with other medical experts and consider the patient’s other health conditions.
Patients getting ready for a PTC procedure may often feel dehydrated which might put them at risk for liver and kidney problems. To prevent this, doctors give fluid through an IV (a tube that goes into a vein) right after the patient is referred for the procedure. They also keep a close eye on the patient’s blood clotting ability and make corrections as needed. If needed, they might give a product called fresh frozen plasma before, during, or after the procedure to help control bleeding.
Lastly, it’s advised to have an anesthesiologist (a doctor who specializes in providing anesthesia) around during the procedure. This is especially important for patients with existing health conditions or advanced needs for managing their breathing. This helps ensure the best possible patient safety and management throughout the procedure.
How is Percutaneous Transhepatic Cholangiography performed
PTC is a medical procedure used by doctors to see biliary tract, which is a path by which bile is secreted by the liver to reach the small intestine. Let’s break down how this is done:
Getting the Patient Ready:
The patient is made to lie down comfortably on their back, giving the doctors full access to their liver area. This area is then cleaned and prepared for the procedure in a germ-free manner.
Anesthesia:
This procedure can cause a bit of pain, as a tube needs to pass through the skin, through some muscles, and into the liver. So, the patient is given local anesthesia (numbing a small area) and moderate sedation (medication to calm and help them relax). If more steps like a biopsy (removal of tissue for testing) or stenting (tubes to keep a passage open) are needed, deeper sedation may be given.
Getting Access and Creating a Pathway:
The preferable approach is to get to the right bile duct from the middle side of the body, just beneath a bone called the tenth rib. There are other methods like through the left side of the upper belly or through the gallbladder, which can be decided based on the suspected condition. A machine called an ultrasound should be used to guide the doctors when trying to make a pathway into the bile duct.
By performing a few steps of exchanging a wire and a tube, bile will be suctioned, confirming that they have reached the bile duct. Once the needle is at the point desired within a bile duct, the doctor will, under the guidance of an X-Ray machine, inject a special dye through the needle into the bile duct system. This dye will fill the bile ducts and highlight them, helping the doctor see any abnormalities, like blockages or narrow spots. The findings from this will then guide the next steps of treatment, including biliary drainage (removing excess bile), widening the duct or placing stents. After all procedures are done, the needle is taken out and pressure is applied at the insertion point to avoid bleeding. A clean dressing may be placed at the spot.
Care after the Procedure:
The patient is observed for a short while to make sure there are no complications immediately after the procedure. They may be advised to avoid vigorous activities for some time after the procedure.
Possible Complications of Percutaneous Transhepatic Cholangiography
PTC, a form of surgery that aids in draining bile from your liver, is generally safe, but as with any medical procedure, there are risks and possible complications. These occur in about 2 to 10% of cases. Common problems include infection in the bile tract, bleeding, bile leaks, blockages, and a condition called pneumothorax, where air gets trapped in the space around your lungs. Here’s a little more info on what these complications can look like:
* Bleeding: Some people might experience bleeding after the procedure, happening in about 2 to 3% of patients. This can take different forms, like internal or external bleeding. Bleeding can be minor or severe and may require a blood transfusion or further procedures to stop it. If bright red blood appears, it could mean that an artery was injured during the surgery. In such cases, further examinations should be performed to locate and treat the injury. To fix this, a stent, a tube that serves to keep the passage open, might be placed at the injury site, or the area could be blocked with small metal coils to control bleeding.
* Bile leak: This can happen if your bile duct is accidentally perforated during the procedure, leading to the leaking of bile into your stomach or chest. This can cause inflammation or infection. If bile leakage does happen, it’s usually treated by repositioning or upsizing the catheter used. The small collection of bile, or ‘biloma’, typically resolves on its own as your body absorbs the fluid. However, you might need drainage if it becomes painful or infected.
* Infections: Despite the use of antibiotics during the surgery, the process could expose your body to bacteria, especially at the site where the puncture was made. The common complications are bloodstream infections (sepsis) and biliary tract infections arising from bacteria in your blood. These are usually treated with antibiotics.
* Pain: Some people might feel discomfort or pain where the surgical cut was made, or even in their stomach during or after the surgery. This is typically temporary and can be managed with medications.
* Pancreatitis: Sometimes the medical instrument used during this surgery can irritate your pancreatic duct, causing inflammation to occur, which is referred to as pancreatitis.
* Pneumothorax: There’s a risk of air getting trapped around your lungs, especially if the surgical cut to your abdomen is near your diaphragm. This risk is particularly high if you have an underlying lung disease.
* Allergic reactions: Some people might suffer reactions to the dye used for observation during the surgery, which can range from minor skin irritation to severe allergic reactions.
* Electrolyte depletion: If a lot of fluid is being drained from your body, this might disrupt the balance of minerals in your body, which would need to be replaced.
* Damage to adjacent organs: In rare cases, neighboring organs such as the lung, gallbladder, or bowel can get injured during the procedure, which would need additional treatment.
* Catheter dislodgement: If the catheter, the thin tube placed in your body during the surgery, gets dislodged or releases itself, it needs to be repositioned or reinserted.
In extremely rare scenarios, PTC can increase the risk of death, as seen in multiple studies. However, it’s crucial to remember that this is a generally safe procedure with proven results, and you should always listen to the advice given by your medical professional while exploring your options.
What Else Should I Know About Percutaneous Transhepatic Cholangiography?
Percutaneous transhepatic cholangiography (PTC) is a valuable tool in diagnosing and treating diseases that affect the biliary tract, which includes parts of the body such as the gallbladder and bile ducts. This procedure allows doctors to see both the inside and outside of your liver’s bile ducts, which can help detect conditions like bile duct narrowings, stones, tumors, or birth defects.
One of the other great things about PTC is that it can also be used to treat some of these conditions. This includes procedures like Percutaneous transhepatic biliary drainage (PTBD), where a tube is inserted to drain bile, placing stents to keep bile ducts open, and removing stones from the bile ducts. These actions can significantly influence how patients are treated for hepatobiliary disorders, which are diseases that affect the liver, gallbladder and bile ducts. By using PTC, treatments can be less invasive which ultimately helps patients recover better.
