Biliary Tap (Percutaneous Transhepatic Biliary Drainage): Uses and Applications
Percutaneous transhepatic biliary drainage (PTBD) is primarily used for decompression of obstructed biliary systems when endoscopic approaches have failed or are not feasible, particularly in cases of malignant obstruction, biliary strictures, or acute cholangitis. 1
Primary Indications
Biliary Decompression
- Obstructive Jaundice: When biliary obstruction causes jaundice, particularly in malignant cases such as cholangiocarcinoma or pancreatic cancer 1
- Failed ERCP: When endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful or not possible due to:
- Altered anatomy (e.g., Roux-en-Y reconstruction)
- Inaccessible papilla
- Unsuccessful biliary cannulation 1
- Acute Cholangitis: For urgent decompression in severe cholangitis with sepsis when ERCP fails 1
Diagnostic Applications
- Biliary Stricture Evaluation: To obtain cholangiographic images and assess the extent of bile duct involvement 1
- Cytology Collection: Allows bile sampling for cytology in suspected malignancy 1
- Anatomical Mapping: Delineates biliary anatomy prior to surgical intervention 1
Therapeutic Applications
- Stent Placement: Facilitates internal biliary stenting for long-term drainage 1
- Stone Removal: Enables removal of biliary stones when ERCP is not possible 1
- Biliary Leak Management: Treatment of post-operative biliary leaks 1
- Rendezvous Procedures: Assists in difficult ERCP cases by providing guidewire access 1
Specific Clinical Scenarios
Malignant Obstruction
- Used for palliative drainage in unresectable tumors 2
- Allows chemotherapy administration by reducing bilirubin levels 2
- Provides preoperative biliary decompression in selected cases 3
Post-Liver Transplant Complications
- Management of anastomotic strictures or bile leaks 1
- Treatment option when ERCP fails in transplant recipients 1
Benign Biliary Disease
- Management of benign biliary strictures refractory to endoscopic therapy 4
- Treatment of sclerosing cholangitis with multiple strictures 1
Technical Considerations
Procedure Approach
- Percutaneous access to the biliary system through the liver
- Cholangiography to define anatomy and pathology
- Guidewire placement across obstruction when possible
- Placement of internal/external or external drainage catheter 1
Types of Drainage
- External Drainage: Bile drains to an external collection bag
- Internal-External Drainage: Allows drainage both externally and internally to the duodenum
- Internal Drainage: Placement of stents to restore bile flow to the intestine 1
Complications and Limitations
Potential Complications
- Hemorrhage (including hemobilia)
- Biliary peritonitis
- Cholangitis
- Pneumothorax
- Catheter tract tumor seeding in malignant cases 1
Success Rates and Outcomes
- Technical success rates of 95-100% in experienced hands 1
- Major complication rates of approximately 7% 1
- Resolution of sepsis in 100% of patients within 24 hours when performed for cholangitis 1
Clinical Decision Making
PTBD vs. ERCP
- ERCP remains first-line for distal biliary obstruction (success rate >90%) 1
- PTBD is indicated when:
- ERCP fails (technical failure in 5-10% of cases)
- Proximal hilar obstruction is present
- Surgically altered anatomy prevents endoscopic access 1
Emerging Alternatives
- EUS-guided biliary drainage is becoming an alternative to PTBD when ERCP fails 5
- Combined percutaneous-endoscopic approaches (rendezvous techniques) 1
Remember that while PTBD is highly effective, it carries higher complication rates than ERCP and should be reserved for cases where endoscopic approaches have failed or are contraindicated.