how to do a percutaneous transhepatic cholangiogram (PTC)

 

help

 

hopefully theyre obstructed, could make it easier

use the Bos Sci Flexima 10F, 35 cm firm biliary catheter

can use similar 21G access set used for nephrostomy, either Greb, or Uresil kit

10-12 F dilators

?? anything else

 

techinque:

classic teaching is to enter the right sided ducts in following fashion:

10-11 rib interspace, just anterior to mid-ax line, and aiming needle towards the T12 or L1 vertebral body

anterior ducts project inferior (right lobe)

posterior ducts project superior (right lobe)

using the 21 gauge trocar needle, advance the needle in the path as above

with needle in place, then remove stylet, attach 50% contrast with tubing to the cannula and infuse contrast as you pull back looking for opacification of a duct.  you may see blood vessels, portal vein, hepatic veins, HA.  biliary contrast should stagnate a bit, appear tubular and enlarged in the case of obstruction

can consider two stick technique where you puncture centrally to opacify the ducts and then puncture again peripherally to get a "biliary radical"

of note want to stay peripheral to prevent bleeding (hemobilia down the line and poss. PSA formation)

once have access, want to send the 018 wire in the kit down into the biliary system

if possible want to get past obstruction and get access to duodenum to place int-ext drain

after wire is down, exchange needle cannula for 5F transitional sheath dilator, goal is to get 035 wire down

can use amplatz (preferred) but can use glidewire to pass obs if need be, then change over via glidecath or berenstein

once have amplatz access through radical and with distal tip in duodenum with purchase, start placing int-ext catheter

use dilators to dilate subcu tract

difficult part is getting catheter over potential hump in alignment of the wire due to access in a inferior duct relative to the hilum

once get past this with stiff part, advance catheter till distal coil within bowel

want side holes in bowel and proximal side holes proximal to obstructed ducts.  basically want to bridge the obstruction with sideholes above and below obstruction (form of stenting)

once catheter in place take final image and can infuse contrast to prove function of catheter

place external drain bag and drain stitch.  case complete

 

How to perform brush biopsy

 

usually if there is biliary obstruction, could be bile duct malignancy, ie klatskin

want to obtain sample of cells

the brush biopsy instrument is like that thing that is used to floss teeth

advance a sheath over the amplatz until you are at the lesion

place biopsy device into sheath

unsheath device and swirl instrument to obtain cells

resheath the device and remove instrument and sheath

place device into sterile specimen cup

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how to change a large french size biliary catheter such as for benign biliary stricture protocol

use a berenstein or other angled catheter and twirl to get past sideholes

then place amplatz to deform distal pig

can do sheath cholangiogram, 7F sheath has radiopaque marker and is helpful is also simliar size to 8F catheter

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to do clamshell biopsy

advance sheath to level of stricture or narrowwing

advance device to level

in some sense you want to unsheath the device

the device tells you how to open and close

can wedge device into tissue

take a few biopsies

to place drain

simply place over amplatz as any other

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