What is involved in a PTC (Percutaneous Transhepatic Cholangiography) procedure?

Percutaneous Transhepatic Cholangiography (PTC) Procedure

Percutaneous Transhepatic Cholangiography (PTC) is an invasive diagnostic and potentially therapeutic procedure that involves needle puncture of the liver to access and visualize the biliary tree, primarily used when less invasive methods like ERCP have failed or are not feasible. 1

Procedure Components

Pre-procedure Preparation

• Patient assessment for coagulation status
• Informed consent explaining risks and benefits
• Administration of prophylactic antibiotics if indicated
• Sedation and local anesthesia

Technical Procedure Steps

1. Liver Puncture: Using a Chiba needle under ultrasound guidance to access dilated intrahepatic bile ducts 2
2. Contrast Injection: Radiographic contrast medium is injected to visualize the biliary tree
3. Selective Catheterization: When possible, a catheter is advanced into the common bile duct 2
4. Imaging: High-quality cholangiograms are obtained to visualize the biliary anatomy and identify any obstruction
5. Potential Drainage: In cases of obstruction, the catheter may be left in place for external bile drainage 2

Clinical Applications

PTC is primarily indicated in the following scenarios:

• When ERCP has failed or is not feasible 1
• For diagnosis of biliary obstruction when conventional methods are inconclusive 2
• For therapeutic decompression in cases of cholangitis 1
• For stent insertion in irresectable tumors 1
• For evaluation of bile duct strictures 3

Diagnostic Value

PTC provides critical information about:

• Presence and level of biliary obstruction 1, 2
• Extent of tumor involvement in the bile ducts 1
• Bile duct anatomy prior to surgical intervention 4
• Differentiation between obstructive and non-obstructive jaundice 2

Complications

The overall incidence of complications ranges from 6.9% to 12.9% 5:

Mild Complications

• Cholangitis and bacteremia (associated with drainage and tract dilation)
• Catheter migration or blockage
• Minor pain or discomfort

Severe Complications (8.2% overall incidence)

• Hemobilia (bleeding into the biliary tree)
• Hemoperitoneum (intra-abdominal bleeding)
• Rupture of the sinus tract
• Bile duct injury 5

Risk Factors for Complications

• Intraductal manipulations (e.g., electrohydraulic lithotripsy or balloon dilation)
• First session of PTC 5
• Multiple punctures to visualize complete anatomy 3

Comparison with Alternative Techniques

PTC vs. MRCP

• MRCP is non-invasive and avoids the risks associated with PTC
• MRCP can provide additional information about fluid collections and portal hypertension 3
• PTC allows for simultaneous therapeutic interventions
• PTC may require multiple punctures to delineate complete anatomy in some cases 3

PTC vs. ERCP

• ERCP is generally favored when available 1
• PTC is indicated when ERCP fails or is not feasible 1
• PTC may be preferred based on the level of obstruction and local expertise 1

Important Considerations

• PTC should be performed with meticulous technique to minimize complications 2, 5
• The procedure should be performed by experienced operators in a cooperative team approach 5
• Patient selection is crucial to minimize complications 5
• PTC has limitations in visualizing pancreatic ducts, which may be necessary for complete evaluation of pancreatic head carcinomas 6

PTC remains an important diagnostic and therapeutic tool in the management of biliary tract diseases, particularly when less invasive methods are not successful or feasible.