Percutaneous Transhepatic Biliary Drainage (PTBD)
Percutaneous Transhepatic Biliary Drainage (PTBD) is a crucial palliative procedure employed in cases of obstructive jaundice, particularly when malignancies have progressed to an unresectable stage. This method serves as a vital intervention to alleviate pain, combat cholangitis, and mitigate pruritus, significantly enhancing the patient’s quality of life. PTBD involves the insertion of a drainage catheter through the skin directly into the bile ducts of the liver, allowing for the effective diversion of bile flow.
Bismuth–Corlette Classification:
| Classification | Description |
|---|---|
| Type I | Proximal CHD/CBD block Primary confluence patent |
| Type II | Primary confluence blocked Secondary patent |
| Type III | Secondary confluence blocked (unilateral) IIIa Right secondary confluence blocked IIIb Left secondary confluence blocked |
| Type IV | IV Bilateral secondary confluence blocked |
Indications of PTBD for Palliation in Obstructive Jaundice:
| Indication | Description |
|---|---|
| Cholangitis | PTBD helps in alleviating cholangitis. |
| Pain Alleviation | PTBD helps in reducing pain associated with obstructive jaundice. |
| Pruritus | PTBD aids in alleviating pruritus, which is common in malignant obstructive jaundice. |
| Serum Bilirubin Reduction | PTBD is used to decrease serum bilirubin (< 3 gm/dl) before initiating chemotherapy. |
| Access for Further Interventions | PTBD allows access to the biliary system for additional palliative interventions like stent placement or brachytherapy. |
Pre - Procedure workup for PTBD patient:
| Step | Description |
|---|---|
| Admission | Patient should be admitted for at least one day to monitor potential major complications, especially sepsis and hemobilia. Continuation of antibiotics is recommended. |
| Antibiotic Coverage | Administer adequate intravenous antibiotics before and after the procedure to prevent cholangitis and sepsis. |
| Pain Management | Administer intravenous analgesics or perform the procedure under conscious sedation for pain alleviation. |
| Fasting/Fluid Intake | Patient should preferably be fasting or on clear liquid diets for at least 4 hours before the procedure. |
Comparison of Right-Sided and Left-Sided PTBD:
| Aspect | Right-Sided PTBD | Left-Sided PTBD |
|---|---|---|
| Advantages | - Easier access to certain parts of the biliary tree. | - Peripheral puncture reduces major vascular injury risk |
| Disadvantages | - Central puncture carries higher vascular injury risk | - Less access to certain parts of the biliary tree |
PTBD vs ERCP:
| Type of Biliary Obstruction | Recommended Procedure | |
|---|---|---|
| Proximal (Hilar Involvement) | PTBD or ERCP | |
| Distal (Beyond Hilum) | ERCP Preferred | |
| Inoperable Cases with Short Life Expectancy (6-12 months) | Metallic Biliary Stenting | |
| Comparison of ERCP and PTBD in Distal CBD Block | ||
| Aspect | ERCP | PTBD |
| Technical Success Rate | Comparable | Comparable |
| Procedure-related Complications | Comparable | Comparable |
| Mortality | Comparable | Comparable |
Stenting in PTBD:
| Type | Description |
|---|---|
| Single Stent | - Site of obstruction is at or beyond the level of primary biliary confluence. |
| Bilateral Stents | - Indicated when secondary confluence (either unilateral or bilateral) is blocked (Bismuth Corlette III and IV). |
| Multiple Stents | - May be required in Type IV block when drainage of more than one major segmental duct is necessary. |
| Configuration Type | Description |
| Y-Shaped | - Restores normal biliary anatomy for drainage through bilateral stenting. |
| T-Shaped | - Allows bilateral stenting even through a unilateral biliary access. |
Metallic vs Plastic stent PTBD:
| Aspect | Metallic Stents | Plastic Stents |
|---|---|---|
| Patency Rate | Longer patency rates | Shorter patency rates |
| Retrieval | Not retrievable | Retrievable |
| Occlusion | Lower occlusion rate | Higher occlusion rate |
Complications related to PTBD:
| Complication Type | Description |
|---|---|
| Minor | - Pain - Peri-catheter leak |
| Major | - Cholangitis, sepsis - Biliary peritonitis - Hemorrhage - Pancreatitis - Pleural effusion, - Pneumothorax (inadvertent pleural puncture) |
| Stent Occlusion | - Tumor ingrowth through stent struts - Tumor overgrowth proximal or distal to the stent |
| Stent Block | - Occurs due to tumor ingrowth or overgrowth |
| Stent Migration | - Rare but possible, especially with plastic stents |