PERCUTANEOUS TRANS HEPATIC BILIARY DRAINAGE (PTBD)

      This is uncommonly done procedure to decrease the severity of the infection. The main indication is biliary sepsis where patient is unfit for major procedures like ERCP under general anaesthesia or anatomical limitations like Gastric Outlet Obstruction (GOO).

      This procedure is done with guidance of ultrasonography with fluoroscopic guidance or with computerized tomography. Here, a thin drainage tube is passed into the biliary system from the skin through the liver into the biliary system over a guide wire. This procedure is done in sterile condition with conscious sedation.

      Under radiological guidance, local anaesthetic agent will be injected into the surrounding area where the catheter will be inserted.  A fine needle is then inserted under ultrasound and fluoroscopic guidance into the bile ducts in the liver. Dye will be injected to confirm the successful entry into the ductal system. A fine guide wire will be passed into the dilated biliary system. Over this guide wire a cannula will be passed into the biliary system. Aspiration of bile confirms that the cannula is in the biliary system only. The same can be confirmed with injection of contrast into the biliary system. This injected dye confirms the biliary tree and also give the anatomy of the biliary tree. At this stage, next step is to manipulate the guide in to the duodenum through the ampulla of Vater. If the guide wire reaches the duodenum, a catheter can be place over the guide wire and so it drains the infected bile into duodenum and also exteriorly. So, this PTBD procedure will drain the infected bile out and so the patient will recover fast. The drainage tube will be left for longer duration till the infection subsides or definitive procedure is done.

      The first technical difficulty with this procedure is that limited availability of the experienced interventional radiologist. There are some anticipated complications related to PTBD, like bleeding and bile leak from the liver entry point. In these situations, the blood or bile will be collected inside the abdominal cavity and may end with more complications. So, it has to be titrated as per the patient requirement and availability of the facilities.

      The contraindications for PTBD are severe coagulopathy, chronic liver disease and ascites. There will be technical difficulty in case of non-dilated biliary system in which reaching the biliary system will be difficult.