Percutaneous Biliary Drainage

Background and indications

Percutaneous transhepatic biliary drainage (PTBD) involves inserting a drain through the hepatic parenchyma into dilated bile ducts to decompress obstructive jaundice. It is indicated when endoscopic drainage (ERCP) is impossible or has failed: high biliary obstruction (Klatskin tumor, intrahepatic cholangiocarcinoma), post-surgical anatomy (biliodigestive diversion), and technically impossible ERCP.

PTBD can be definitive (external drainage or percutaneous stent) or temporary (decompression before surgery or chemotherapy).

Pre-procedure assessment

Assessment includes biliary CT or MRI (obstruction level and cause, biliary dilation mapping), hepatic blood panel (bilirubin, coagulation), and oncologic tumor board if tumor context. Intrahepatic biliary dilation is necessary for percutaneous drainage.

Procedure

Under local anesthesia and sedation, a fine needle is inserted into a dilated intrahepatic bile duct under fluoroscopic and/or ultrasound guidance (right intercostal or left epigastric approach). Cholangiography opacifies bile ducts and localizes the obstruction. A guidewire is crossed through the obstruction (if possible, "rendezvous" with an internal stent). An external drain (8-12F) is placed, later converted to internal-external drain or metallic biliary stent. The procedure takes 1 to 2 hours.

Results and scientific evidence

Technical success rate is 90-98%. Bilirubin decreases by 50% within the first 3-5 days. For Klatskin tumors, percutaneous drainage offers 80-90% palliation rate. Metallic stent offers 6-12 month patency (vs 3-4 months for plastic stents).

Risks and complications

Cholangitis/biliary sepsis (5-10%), hemorrhage (hemobilia: 2-5%), bile leak (2-5%), drain displacement (5-10%). 30-day mortality is 2-5%, related to underlying disease. Systematic antibiotic prophylaxis is administered.

Recovery

2-5 day hospitalization. External drain is initially connected to a collection bag. Drain change or conversion to internal stent at 1-2 weeks.

Practical information

The procedure is performed as an inpatient. It is performed by an interventional radiologist, in coordination with the gastroenterologist, hepatic surgeon, and oncologist.