Biliary Drainage

Authors:  Dr Mark Goodwin*
                        Dr James Burnes*

General introduction to biliary drainage

Biliary drainage, sometimes also referred to as a PTC (percutaneous transhepatic cholangiogram), is an invasive procedure carried out by a radiologist for biliary obstruction. It is usually carried out for malignant biliary obstruction (i.e. due to cholangiocarcinoma or metastases), but benign biliary strictures can also occur.

What are the prerequisites for having a biliary drainage done?

1. Patients need to have appropriate medical imaging before a biliary drainage. This usually involves an abdominal CT scan. Pre-procedure imaging with magnetic resonance cholangiopancreatography (MRCP) may be required for more complex cases.
2. The patient should have recent (within 4 weeks) FBC, LFTs and coagulation profile results available. Because of the risk of haemorrhage, it is usual for anticoagulation (warfarin and heparin) and antiplatelet therapy (aspirin and clopidogrel) to be ceased before biliary drainage, if possible (warfarin is usually stopped 5-7 days before and the INR rechecked just before the procedure; clopidogrel should be stopped at least 7 days before). If the risks of ceasing these medications are considered too high, such as in patients with recently inserted stents or other cardiac intervention, this should be discussed with the radiologist before requesting the procedure. Anticoagulants and antiplatelet therapy are usually restarted within 24-48 hours of the procedure; if in doubt, check with the radiologist who carried out the biliary drainage.
3. The patient should be fasted for 4 hours before the procedure.

What are the absolute contraindications for a biliary drainage?

• Uncorrectable severe coagulopathy.
• Unsafe access (e.g. interposed bowel).

What are the relative contraindications for a biliary drainage?

• Allergy to iodinated contrast material.
• Large volume ascites (may require drainage before the procedure).
• Multifocal segmental biliary obstruction (e.g. caused by multiple liver metastases-biliary drainage may be ineffective).

What are the adverse effects of a biliary drainage?

The risk to an individual depends very much on the specific clinical scenario (e.g. comorbidities, presence of disseminated cancer). However, published data suggest the following overall major complication rates:

• sepsis 2.5%;
• local haemorrhage 2.5%;
• localised inflammatory/infectious complications (abscess, peritonitis, cholecystitis, pancreatitis) 1.2%;
• pleural complications(pneumothorax/haemothorax/empyema) 0.5%;
• death 1.7%.¹

Are there alternative imaging tests, interventions or surgical procedures to a biliary drainage?

Some biliary interventions can be achieved endoscopically (ERCP), avoiding the need for percutaneous hepatic puncture and its associated risks. In some cases though, ERCP is not technically possible (such as where there is no endoscopic access, i.e. previous gastrectomy). All biliary drainage referrals should therefore be discussed with the radiologist and the relevant imaging should be available so that the correct decision for that individual patient can be made.

Useful websites about biliary drainage:

Cardiovascular and Interventional Radiological Society of Europe:
cirse.org/index.php?pid=1016

Reference:

1. Burke DR et al. Quality improvement guidelines for percutaneous transhepatic cholangiography and biliary drainage. J Vasc Interv Radiol. 2003, 14: S243–S246.

*The author has no conflict of interest with this topic.

Page last modified on 29/3/2017.