What are the indications for Percutaneous Transhepatic Biliary Drainage (PTBD)?

Indications for Percutaneous Transhepatic Biliary Drainage (PTBD)

PTBD is indicated as a second-line procedure when endoscopic biliary drainage has failed or is not technically feasible, and serves as the primary approach in specific clinical scenarios including hilar obstruction (particularly in Asian practice patterns), post-transplant biliary complications when endoscopy fails, and acute cholangitis with failed ERCP. 1

Primary Clinical Indications

Failed or Impossible Endoscopic Access

• PTBD becomes the procedure of choice when ERCP has failed or cannot be performed due to altered anatomy, tumor obstruction blocking endoscopic access, or technical failure 1
• Meta-analysis demonstrates no significant difference between PTBD and endoscopic drainage regarding mortality, complications, or therapeutic response rates, validating PTBD as an effective second-line therapy 1, 2
• Technical success rates for PTBD reach approximately 90% with short-term clinical success of 70-80% in expert centers 1

Acute Cholangitis and Biliary Sepsis

• PTBD is indicated when endoscopic biliary drainage fails in patients with acute obstructive suppurative cholangitis requiring urgent decompression 1
• For severe (grade 3) acute cholangitis requiring urgent decompression, PTBD serves as the alternative when ERCP is unsuccessful 1
• In septic patients with complete common bile duct obstruction, PTBD becomes part of the multidisciplinary approach when ERCP fails 1

Post-Cholecystectomy Bile Duct Injuries

• PTBD is appropriate for bile leaks and dilated bile ducts following laparoscopic cholecystectomy when endoscopic approaches are unsuccessful or not feasible 1
• For major bile duct injuries (Strasberg E1-E5) with complete loss of continuity, PTBD may be used as a temporizing measure before definitive surgical repair 1
• Technical success of 90% can be achieved even in non-dilated bile ducts with active leakage, though this is more technically challenging 1, 3

Post-Liver Transplant Complications

• PTBD is usually appropriate as initial or alternative therapy for liver transplant recipients with elevated bilirubin and suspected biliary anastomotic stenosis or bile leak, particularly when endoscopic access is difficult 1
• Anastomotic biliary strictures refractory to endoscopic treatment may require PTBD, especially when surgical revision is not immediately planned 1

Hilar and Perihilar Malignant Obstruction

• In Japan and China, PTBD is the preferred method of choice for hilar obstruction (Klatskin tumors), representing a regional practice pattern 1, 4
• For malignant common bile duct obstruction, PTBD serves as an appropriate alternative when endoscopic stenting is not feasible 1
• Percutaneous placement of self-expanding stents has demonstrated safety and effectiveness similar to endoscopically placed stents 1

Palliative Care Settings

• The majority of PTBD procedures (approximately 70%) are performed for palliative treatment of malignant biliary obstruction 5
• PTBD is indicated for palliation when surgical bypass carries prohibitive morbidity and mortality, and endoscopic approaches have failed 1

Important Contraindications and Relative Contraindications

Absolute Contraindications

• Uncorrected coagulopathy is an absolute contraindication to PTBD due to bleeding risk of approximately 2.5%, which increases substantially with coagulation abnormalities 1, 3, 4
• In patients with uncorrected coagulopathy who cannot undergo endoscopic stenting, transjugular bare metal stent insertion may be considered as it avoids violating the liver capsule 1

Relative Contraindications

• Moderate to massive ascites represents a relative contraindication for PTBD as initial access into the ducts becomes more difficult 1, 3, 4
• In the presence of coagulopathy that can be corrected, endoscopic biliary drainage should be attempted first given its lower bleeding risk (1-2% with sphincterotomy) 1

Key Technical Considerations

Timing and Approach

• For acute cholangitis, PTBD should focus on biliary decompression rather than definitive treatment, with minimal manipulation of the biliary tree 1
• Temporary external drain placement may be necessary if obstruction cannot be easily traversed, with conversion to internal/external drain after acute infection resolves 1
• Contrast injection under pressure should be avoided during acute infection to prevent cholangio-venous reflux and worsening septicemia 1

Common Pitfalls to Avoid

• Do not attempt PTBD without first correcting coagulopathy, as bleeding complications increase significantly 1, 3
• Avoid PTBD as first-line therapy when endoscopic drainage is feasible, as ERCP demonstrates lower invasiveness and comparable efficacy 1, 5
• In non-dilated bile ducts with active leakage, recognize the increased technical difficulty and consider whether endoscopic approaches might still be attempted first 1, 3
• Prophylactic antibiotics should be administered before the procedure to prevent cholangitis, septicemia, and bacteremia, as sepsis rates can reach 34.6% without prophylaxis 4, 6