Percutaneous Transhepatic Cholangiogram

Percutaneous Transhepatic Cholangiogram

Introduction to Procedure

We know that undergoing any procedure is a scary experience.  We understand the worry and anxiousness that is associated with surgeries and procedures and aim to walk the road to recovery with you every step of the way. We put this information together using the very helpful handbook, ‘Handbook of Surgical Consent” from Rajesh Nair and David J. Holroyd.  We hope that the following information will answer all your questions and help you with the preparation phase for your procedure.

Description of procedure

PTC is a procedure performed by a radiologist (specialist X-ray doctor) who takes X-ray pictures of the bile ducts which are tubes inside the liver. These tubes normally carry the bile from the liver to the bowel. A thin needle is passed through the skin on the right side between the ribs or in the upper central part of the tummy.

You will more than likely have had other pictures of your liver and bile ducts taken by ultrasound, CT (computed tomography) or MRI (magnetic resonance imaging) scan. PTC is usually recommended either to get more detailed pictures of the bile ducts, or as the start of a procedure such as placing a biliary drainage tube, placing a stent to bypass a blockage in the bile duct, or sometimes to try to widen narrow points in the bile ducts with a balloon.

Endoscopic retrograde cholangiopancreatography (ERCP) is an alternative way of getting access to the bile duct. This involves passing a tube with a camera (the endoscope) through the mouth. If ERCP is the better alternative in your case, the doctors will discuss it with you. PTC is often required when ERCP is not possible or has already been tried and failed. PTC may be the only possible option after some surgical operations. Sometimes PTC and ERCP are used together as a ‘combined procedure’.

You will have to be an inpatient in hospital for this procedure to be performed. In some cases you may be allowed to go home after a short stay in hospital. In other cases this procedure may be part of a longer stay in hospital. Sometimes several visits to the Imaging (X-ray) department are needed to finish all the procedures. This may mean you have to stay in hospital for a week or two or be re-admitted for the later procedures.

Preparation

You should have nothing to eat for 4-6 hours before the procedure. You may drink clear fluids like water or you may have an intravenous drip in your arm.

Your blood will be tested before the procedure. You may need to have an injection of vitamin K or special transfusions to correct blood clotting before the procedure. Very abnormal blood clotting may delay the procedure for a day or two depending on the overall urgency of your condition. If your blood is checked and vitamin K given two days before, then clotting is usually normal at the time of the PTC.

You will have antibiotics either as a tablet or as an injection in a needle in your arm before going to the Imaging Department. A needle in your arm is necessary so that you can receive intravenous sedation and pain killers during the procedure.

You may be in hospital already or you may need to be admitted to hospital specifically on the day of the procedure or the day before the procedure.

Operative techniques

In most cases, percutaneous transhepatic cholangiography (PTC) can be performed via the right midaxillary approach, though a subxiphoid approach is occasionally needed. Some patients 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.

Additional procedures that may become necessary
  • In rare cases there may be more serious bleeding which may need further treatment such as a blood transfusion, more procedures in the Imaging Department to stop the bleeding or in severe cases a surgical operation. There may be leakage of bile from the liver or around the drainage tube. If this happens you may require a change of the type of drainage bag or special dressings. We will also check that the drainage tube is in the right place as sometimes bile leakage can occur because the tube has slipped out of position. Sometimes this will mean you have to go back to the Imaging department to have the tube re-positioned. These risks do not usually cause serious problems to our patients. However, if you suffer any complications, we will treat you as quickly and effectively as we can.
Serious/frequently occurring risks
  • The risks of the procedure have to be considered in combination with your particular situation and degree of illness. In very sick patients the risks are greater, but your doctors will consider your situation carefully and discuss their recommendations with you. You may feel pain during or after the procedure. If you do, please let us know so that you can be given appropriate treatment to stop it. There is a risk of infection within the bile ducts which can lead to a high temperature and generalised shivering. This risk is reduced by giving antibiotics before and after the procedure but in some cases an intravenous drip and further antibiotic treatment is necessary. In the worst cases, this type of infection can be very serious and requires intensive treatment. The procedure may cause bruising or bleeding inside the body. It is quite common to see a small amount of blood in the drainage bag but this is usually not at all serious.
Follow-up or need for further procedure

Aftercare:

  • In certain special cases you may be allowed to leave the hospital after several hours rest in the ward. Most patients stay in the hospital at least one night, and often some days after the procedure. This will depend on your exact condition and whether further procedures have been planned such as replacement of the drainage tube by a permanent internal stent or a surgical operation. You may need to continue antibiotic treatment. If you have any pain as a result of your condition or because of the drainage tube then you will be given pain killers as necessary. The drainage tube and bag are only kept on for a few days in most patients but sometimes we need to keep them in place for longer e.g. a few weeks or even months. In very rare cases, the drainage tube is permanent. If the tube is kept draining for a long time then you will need to drink extra fluid and take extra salt to compensate.

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