Percutaneous transhepatic biliary drainage (PTBD)

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Percutaneous transhepatic biliary drainage (PTBD) is an interventional radiology procedure in which a catheter is inserted percutaneously through the liver parenchyma into a dilated bile duct to decompress the obstructed biliary system. It can provide external, internal–external, or stent drainage.

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Indications

Diagnostic

When ERCP is not possible (e.g., altered anatomy, failed cannulation).
For cholangiography in hilar/complex strictures.

Therapeutic

Nature	Indications
Obstructive jaundice	• Malignant obstruction (cholangiocarcinoma, pancreatic Ca, gallbladder Ca, porta hepatis nodal disease).
• Benign strictures (post-surgical, post-transplant).
Infective / inflammatory	Cholangitis with obstruction.
Biliary leaks/fistulae	e.g., post-cholecystectomy, transplant
Preoperative drainage	Hilar cholangiocarcinoma or before major liver resection.
Palliation	Unresectable malignant obstruction.

Contraindications

Uncorrected coagulopathy.
Massive ascites (relative).
Severe uncontrolled sepsis.
Nondilated biliary tree (technical difficulty).

Technique

Imaging guidance:

Ultrasound to puncture peripheral intrahepatic bile ducts.
Fluoroscopy for cholangiography and catheter manipulation.

![Schematic and case illustration of the choledochoduodenostomy (A) and the hepaticogastrostomy (B). Patient A had a distal bile duct obstruction due to a locally advanced pancreatic head carcinoma. Patient B had a large perihilar metastasis of a small cell lung carcinoma with a complete obstruction of the proximal common bile duct but preserved left-right intrahepatic bile duct communication. The choledochoduodenostomy can be combined with a duodenal stent or an endoscopic gastrojejunostomy if indicated.

Paik WH, Lee TH, Park DH, Choi JH, Kim SO, Jang S, Kim DU, Shim JH, Song TJ, Lee SS, Seo DW, Lee SK, Kim MH. EUS-Guided Biliary Drainage Versus ERCP for the Primary Palliation of Malignant Biliary Obstruction: A Multicenter Randomized Clinical Trial. Am J Gastroenterol. 2018;113:987-997. Hindryckx P, Degroote H, Tate DJ, Deprez PH. Endoscopic ultrasound-guided drainage of the biliary system: Techniques, indications and future perspectives. World J Gastrointest Endosc 2019; 11(2): 103-114 [PMID: 30788029 DOI: 10.4253/wjge.v11.i2.103]](attachment:5823ac76-966c-4ee0-8342-9bc1f62dcccc:WJGE-11-103-g001.png)

Schematic and case illustration of the choledochoduodenostomy (A) and the hepaticogastrostomy (B). Patient A had a distal bile duct obstruction due to a locally advanced pancreatic head carcinoma. Patient B had a large perihilar metastasis of a small cell lung carcinoma with a complete obstruction of the proximal common bile duct but preserved left-right intrahepatic bile duct communication. The choledochoduodenostomy can be combined with a duodenal stent or an endoscopic gastrojejunostomy if indicated.