What is a Percutaneous Transhepatic Cholangiography (PTC) drain?

What is a PTC Drain?

A PTC (Percutaneous Transhepatic Cholangiography) drain is a catheter placed through the skin and liver directly into the bile ducts to provide external drainage of bile when the normal biliary pathway is obstructed or when endoscopic access has failed. 1

Primary Function and Mechanism

• PTC serves dual diagnostic and therapeutic purposes: it can identify the exact location and nature of bile duct injuries or obstructions while simultaneously providing biliary decompression through catheter drainage. 1

• The procedure involves percutaneous transhepatic intubation of bile ducts, creating an external drainage pathway that bypasses biliary obstruction. 2

• The transhepatic approach (through liver tissue) is preferred because it reduces the risk of bile leak, allows the drain to remain in place for longer periods, and leads to quicker maturation of a drainage tract. 1

Clinical Role in Treatment Hierarchy

PTC drainage should be reserved as a second-line approach, used only when endoscopic retrograde cholangiopancreatography (ERCP) fails or is not feasible due to anatomical limitations. 3, 4

• ERCP remains the first-line treatment for biliary decompression in moderate to severe acute cholangitis, with success rates exceeding 90% and mortality rates below 1%. 3

• PTC becomes the preferred option when ERCP cannot access the biliary tree, such as in patients with surgically altered anatomy (Roux-en-Y), unsuccessful biliary cannulation, or anatomically inaccessible papilla. 4

• In cases of ERCP failure, PTC allows for an extraluminal percutaneous endoscopic rendezvous procedure with stent placement to restore bile duct continuity. 1

Specific Indications

• Malignant biliary obstruction requiring palliative drainage in patients with unresectable tumors (pancreatic cancer, cholangiocarcinoma). 5

• Bile duct injuries following cholecystectomy when ERCP has failed to manage the leak or stricture. 1

• Postoperative bile leaks from biliodigestive anastomoses requiring external decompression. 2

• Preoperative biliary drainage to improve liver function and general condition before radical or palliative surgery in patients with obstructive jaundice. 2

• Biliary strictures (both anastomotic and non-anastomotic) that cannot be accessed endoscopically, particularly in liver transplant patients. 1

Technical Considerations

• The transhepatic route is technically preferred except in patients with severe liver disease and coagulopathy, as it decreases risks of bile leak and portal vessel injury but carries risks of pneumothorax and parenchymal bleeding. 1

• PTC can be technically challenging when intrahepatic bile ducts are not dilated, making needle access more difficult. 1

• Catheter placement success rates reach approximately 90-97%, with technical failure occurring due to small gallbladder lumen, thin walls, or porcelain gallbladder. 1, 5

Significant Complications and Risks

PTC carries substantial risks that make it less favorable than endoscopic approaches, including:

• Biliary peritonitis from bile leakage into the abdominal cavity. 1, 4

• Hemobilia and peritoneal hemorrhage from vascular injury. 1, 4, 2

• Cholangitis and sepsis from bacterial contamination. 1, 2, 6

• Pneumothorax when using transhepatic approach. 4

• Liver abscesses and hematoma formation. 4

• Catheter-related complications including dislodgement, obstruction from duodenobiliary reflux, and patient discomfort from external drainage. 4, 2, 7

• The overall complication rate ranges from 3.4% to 6.6%, with mortality rates of 1.3-2% in historical series. 2, 6, 5

Catheter Management and Duration

• Drainage duration typically ranges from 3-6 weeks (average 1 month) to allow for tract maturation before catheter removal. 1

• Cholangiography should be performed 2-3 weeks after placement before drain removal to confirm biliary tree patency and absence of obstruction. 1

• Patients with diabetes, ascites, long-term steroid therapy, or malnutrition require longer drainage periods as these conditions hinder tract maturation. 1

• Recurrent catheter obstruction from intestinal content reflux may require modified catheters with antireflux mechanisms. 7

Common Pitfalls to Avoid

• Do not use PTC as first-line therapy when ERCP is feasible, as this exposes patients to unnecessary complications with higher morbidity than endoscopic approaches. 3, 4

• Avoid attempting PTC in patients with severe coagulopathy without correction, given the high bleeding risk. 1

• Do not remove catheters prematurely (before 3-4 weeks) without confirming tract maturation via cholangiography, as this increases bile leak risk. 1

• Recognize that PTC cannot visualize ducts upstream or downstream from complete obstructions, limiting its diagnostic utility compared to MRCP. 1