Interventional Radiology

PTBD - Percutaneous Transhepatic Biliary Drainage

PTBD relieves a blocked bile duct by placing a drainage tube through the skin and the liver under ultrasound and X-ray guidance, when the endoscopic route has failed or cannot reach the blockage. It explains why bile must be drained, which cancers and benign strictures cause obstruction, how PTBD compares with ERCP and endoscopic ultrasound drainage, the procedure, living with a drain, the risks, what the studies show, and how patients from abroad arrange it in Istanbul.

About This Department

Interventional radiology

When bile cannot leave the liver, the skin turns yellow, the itch becomes unbearable and infection follows. A tube placed through the skin into a bile duct drains it within hours. Relief first. The cause afterward.

Percutaneous transhepatic biliary drainage, or PTBD, is a procedure in which an interventional radiologist passes a needle through the skin and the liver into a dilated bile duct under ultrasound and X-ray guidance, and leaves a tube that drains the bile out through the skin, into the bowel, or both. Radiologists turn to it when the ducts are blocked by a tumor, a stone or a scar and the endoscopic route through the mouth has failed or cannot be used. In a ten-year analysis of 385 patients and 2,468 drains, a drain-related complication, most often blockage, displacement or infection, affected 23 percent of drains and 40 percent of patients over the course of their treatment (Nennstiel and colleagues, Journal of Clinical Gastroenterology, 2015). A meta-analysis of nine studies and 483 patients found that endoscopic ultrasound-guided drainage, where available, had fewer adverse events and fewer repeat procedures than PTBD (Sharaiha and colleagues, Gastrointestinal Endoscopy, 2017). This page explains why bile must be drained, who needs PTBD, how it compares with the endoscopic routes, the procedure itself, life with a drain, the risks, what the studies show, and how patients from abroad arrange it at Biruni Hospital in Istanbul.

Percent of 2,468 percutaneous biliary drains that blocked, moved or became infected over ten years of follow-up

483

Patients in nine comparative studies of endoscopic ultrasound drainage against PTBD when ERCP had failed

Percent mortality with percutaneous drainage against 11 percent with endoscopic drainage in the trial of resectable bile duct cancer, which was stopped early

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What PTBD is

The liver makes about a liter of bile a day and sends it down a tree of ducts into the intestine. Block the tree anywhere below the branches and the bile backs up, the ducts swell, and the substances bile carries, bilirubin above all, spill into the blood. PTBD finds one of the swollen branches with an ultrasound probe on the skin, punctures it with a fine needle, threads a wire down the duct, and slides a tube over the wire. Bile flows the moment the tube is in.

Why not go through the mouth first?

The endoscopic route, ERCP, is preferred whenever it is possible, because it leaves no tube on the outside, punctures nothing, and carries a lower risk of bleeding. A gastroenterologist passes a scope to the duodenum, enters the bile duct from below and places a stent across the blockage. ERCP fails or cannot be attempted in about one patient in ten, when the tumor has distorted the duodenum, when previous surgery has rerouted the bowel, when the blockage sits high in the liver where the ducts have split, or when the patient is too unwell to lie for a long endoscopy. Those patients come to PTBD.

Why bile must be drained

Jaundice by itself harms nobody. What it signals does.

What happens if a blocked bile duct is not drained?

Four things, in roughly this order. The itch, from bile salts in the skin, which keeps patients awake and does not respond to ordinary remedies. Infection, called cholangitis, because stagnant bile behind a blockage breeds bacteria that reach the blood within days, with fever, shaking chills and, untreated, septic shock. Liver damage, since bile pressure inside the liver injures the cells and, over weeks, the liver begins to fail. And the loss of every other treatment, because chemotherapy cannot be given to a patient with a bilirubin above a certain level and surgery on a jaundiced liver carries far higher risk. Drainage lifts all four. A patient with cholangitis is drained within 24 hours, whatever the cause.

Who needs it

The patient with a blocked duct and no way through from below.

Which cancers block the bile ducts?

Cancer of the head of the pancreas, which wraps around the lower duct, is the commonest. Cancer of the bile duct itself, cholangiocarcinoma, especially the type at the junction of the right and left ducts, called a Klatskin tumor, which the endoscope reaches poorly. Cancer of the gallbladder. Lymph nodes in the liver hilum enlarged by lymphoma or by metastases from stomach, bowel or breast cancer. And liver metastases pressing on the ducts from within. In each, PTBD relieves the jaundice so that chemotherapy or surgery can go ahead, or, when neither is possible, so that the patient is comfortable.

Causes of biliary obstruction and the usual first route
Cause	First choice	When PTBD is used
Pancreatic head cancer	ERCP with a stent	ERCP fails, duodenum invaded
Hilar cholangiocarcinoma, Klatskin tumor	Depends on the level and the plan for surgery	High blockage, both sides need draining, or before major liver resection
Gallbladder cancer, hilar nodes	ERCP or PTBD	Complex anatomy at the hilum
Stones in the bile duct	ERCP	Stones above a stricture, or after gastric bypass
Benign stricture after surgery or transplant	ERCP	Bile duct rerouted to the bowel so the scope cannot reach
Leak from the bile duct after surgery	ERCP	Diversion through a percutaneous drain when ERCP cannot reach

Is it only for cancer?

No. About a third of PTBD procedures in the ten-year German series were for benign disease. Strictures that form after gallbladder surgery, after a liver transplant, or in a chronic inflammatory disease of the ducts called primary sclerosing cholangitis are dilated with a balloon through the percutaneous track, sometimes in several sessions, and stones that the endoscope cannot reach are pushed into the bowel or broken up through the same route. In these patients the tube is temporary and the goal is a duct that stays open without it.

PTBD, ERCP or endoscopic ultrasound

Three routes into the same duct. From below, through the mouth. From the side, through the stomach wall under ultrasound, and from above, through the skin and the liver, which is the route this page describes.

The newer alternative

What is EUS-guided biliary drainage?

A procedure in which an endoscopist uses an ultrasound probe on the tip of the scope, inside the stomach or duodenum, to see the dilated bile duct through the gut wall, puncture it, and place a stent that connects the duct directly to the gut. It leaves nothing outside the body. The meta-analysis of nine studies and 483 patients found technical success equal to PTBD, better clinical success, fewer adverse events, with an odds ratio of 0.23, and fewer repeat procedures, with an odds ratio of 0.13, and concluded that where the expertise exists it may be preferred over PTBD when ERCP fails (Sharaiha and colleagues, 2017). The hospital offers both, and the choice depends on the anatomy, the level of the blockage and whether surgery is planned.

PTBD keeps three advantages. It reaches a blockage high in the liver where the ducts have already divided, which neither endoscopic route reaches well. It provides a track through which a surgeon or a radiologist can later work, dilating a stricture, removing stones or placing a stent under direct control. And it works in a patient too unwell for a long endoscopy under sedation, since it can be done under local anesthetic in twenty minutes at the bedside of an intensive care unit if need be.

The procedure

Thirty to sixty minutes. Local anesthetic and sedation for most. General anesthesia for a few.

Before

Blood tests for clotting, platelets, bilirubin and kidney function. Antibiotics through a vein, always, because the bile behind a blockage is assumed to be infected. Blood thinners paused. A recent CT or MRI on the screen so that the radiologist knows which side of the liver to enter and which ducts are dilated.

Positioning

On the back, right arm above the head for a right-sided approach through the lower ribs, or a left-sided approach below the breastbone when the left ducts are the ones dilated or the patient will manage the drain better on that side.

Anesthesia

Local anesthetic into the skin and the liver capsule, with sedation through a vein and an anesthesiologist present. The puncture of the liver capsule and the passage of the tube are the moments felt most, and both are brief.

Two tools guide the needle. Ultrasound finds the dilated duct and shows the needle entering it. X-ray fluoroscopy, once contrast has been injected through the needle, shows the whole tree, the level and shape of the blockage, and the wire and tube as they advance. The radiologist tries to cross the blockage at the first sitting so that bile can drain into the bowel as nature intended, and succeeds in most cases. When the blockage cannot be crossed, an external drain is left and a second attempt made a few days later once the swelling has settled.

Puncture. A fine needle through the skin between the ribs into a peripheral duct, guided by ultrasound.
Contrast. A few milliliters of dye outline the ducts and show the blockage on X-ray.
Wire. A guidewire passes down the duct and, where possible, through the blockage into the duodenum.
Dilation. The track through the liver is widened over the wire with a series of dilators.
Drain. A soft tube with side holes, 8 to 12 French in size, is placed over the wire, its tip in the bowel or above the blockage, its outer end fixed to the skin and connected to a bag.
Check. Contrast through the drain confirms position and flow. A dressing goes on. The patient rests for four hours with blood pressure and pulse checked.

Three kinds of drain

External drain. The tube ends above the blockage and all the bile leaves through the bag. Used when the blockage cannot be crossed, or when the bile is infected and needs to be flushed out completely for a few days.
Internal-external drain. The tube crosses the blockage, with holes above and below, so that bile can drain into the bowel when the outside end is capped and out into the bag when it is open. The usual arrangement for the weeks after the procedure.
Metal stent. A self-expanding mesh tube placed across the blockage through the same track, after which the external tube is removed and nothing remains outside the body. Chosen for a cancer that will not be operated on, since it stays open for months and spares the patient the drain.

Living with a drain

The bag fills. The yellow fades. Then the daily routine begins.

The first days

Bile in the bag is dark and often cloudy at first, then clears. The bilirubin falls by about half every three to four days. The itch settles within a week. Fever in the first day, from bacteria pushed into the blood by the procedure, is common and treated with the antibiotics already running.

Capping

Once the bile is clear and the fever gone, an internal-external drain is capped so that bile drains into the bowel, and the bag comes off. The patient keeps the capped tube for as long as it is needed, flushing it daily.

The exchange

A drain is changed every two to three months, or sooner if it blocks, in a twenty-minute procedure over a wire through the existing track. A metal stent placed through the track ends the need for exchanges.

Occlusion, dislocation and cholangitis were the most common complications observed during PTBD therapy, and the risk factors for cholangitis and occlusion were malignant disease, prior occurrence of complications and bilateral drainage (Nennstiel and colleagues, 2015). A patient who learns to flush the drain and to recognize a blockage early avoids most of them.

Flush. Ten milliliters of sterile saline through the drain once or twice a day, to keep it clear.
Dressing. Changed every two to three days, and at once if wet. The skin around the tube is cleaned and dried and watched for redness.
Watch. Fever, chills, a return of the yellow color or the itch, pain at the site, bile leaking around the tube, or a bag that has stopped filling when it should be open, each means a call the same day.
Live. Showering with the site covered, walking, working, traveling by air with the drain capped and the supplies in hand luggage. Swimming and baths are the two things to avoid.

Risks

Higher than for most procedures done through the skin, because the liver bleeds, the bile is infected and the patients are often frail.

Bleeding

Into the liver, into the duct or into the abdomen, in 2 to 4 percent, usually settling on its own and sometimes needing embolization of the vessel through an artery. The reason clotting is checked and blood thinners are paused.

Infection

Cholangitis or sepsis in the hours after the procedure in a few percent despite antibiotics, treated in hospital with intravenous antibiotics and, where needed, a second drain.

Bile leak

Around the tube or into the abdomen in a small proportion, treated by repositioning or upsizing the drain.

Later

Drain blockage and displacement, the two commonest events of long-term drainage, occur in about a quarter of drains and are handled by exchange. Tumor growth along the track is rare. Death related to the procedure itself is reported at around 1 percent in the large series, nearly always in patients who were already septic or whose liver had begun to fail before the drain was placed, which is the argument for draining early rather than late. Two habits reduce the late complications more than anything the radiologist does at the first sitting. The first is the daily flush, which keeps the side holes clear of the sludge that bile forms when it stands still. The second is the early call, because a drain that has stopped flowing is cleared in minutes on the day it blocks and becomes a septic emergency by the third day, and the patients in the Munich series who did worst were those whose blocked drains went unreported over a weekend.

What the studies show

PTBD has been done for fifty years and its results are known in detail. The studies that matter to a patient now are the ones that compare it with the alternatives.

Three studies

The evidence
Study	What it looked at	What it found
Munich series, 2015, 385 patients, 2,468 drains	Complications of long-term percutaneous drainage over ten years	At least one drain complication in 40 percent of patients and 23 percent of drains. Blockage, displacement and infection commonest. Cancer, previous complications and drains on both sides raised the risk
Meta-analysis, 2017, 9 studies, 483 patients	EUS-guided drainage against PTBD when ERCP had failed	Same technical success. EUS drainage had better clinical success, fewer adverse events and far fewer repeat procedures
DRAINAGE trial, 2018, 54 patients	Endoscopic against percutaneous drainage before surgery for hilar bile duct cancer	Stopped early. Mortality 41 percent after PTBD against 11 percent after endoscopic drainage, with similar drainage complications. More than half the endoscopic group later needed PTBD anyway

What the trial does and does not mean

The DRAINAGE trial enrolled patients with a specific and difficult cancer, at the hilum, who were being prepared for a major liver operation. Its numbers were small and its authors asked for caution. It does not apply to the patient with pancreatic cancer whose ERCP failed, or the patient with a benign stricture. What it does say is that in hilar cancer the choice of route belongs to a team with surgeons, endoscopists and radiologists in the same room, and that PTBD should be the first route only when there is a reason for it.

What the meta-analysis means

That a patient whose ERCP has failed should be asked whether EUS-guided drainage is possible before PTBD is booked, and that a hospital offering PTBD should also offer the alternative. The hospital does.

The honest summary

Last resort and first resort at once.

Last, because the endoscopic routes leave nothing outside the body and carry fewer complications where they work. First, because it works when they do not, it works in the sickest patients, and it reaches the parts of the liver they cannot. A patient who has been told that PTBD is needed should ask why the other routes were not chosen, and a good answer exists in every case where the choice was right.

Coming from abroad

Few patients travel for a drain alone.

PTBD comes first for a patient who arrives jaundiced for cancer treatment, or the second step for a patient whose ERCP failed at home, and it is done in the first days so that the treatment of the cause can follow. A patient with fever and jaundice should be drained where they are, in the nearest hospital, and travel afterward.

What to send

Before travel
Item	Why	Format
MRI or CT of the liver and pancreas	Shows the level of the blockage and which ducts are dilated, which decides the route	Image files rather than the report alone
Bilirubin, liver enzymes, clotting and blood count	Decides urgency and whether blood thinners must be stopped	From the last week
The ERCP report, if one was attempted	Prevents a second failed attempt	With the reason it failed
The pathology and the treatment plan for the cause	Decides whether a temporary drain or a permanent stent is right	Reports and dates
The list of medicines	Bleeding is the main procedural risk	Blood thinners marked

How long do I stay?

A week for the drain alone, covering the review, the procedure, two to three nights in hospital, the capping and the teaching, and the fitness-to-fly check. Patients who stay on for chemotherapy or surgery simply continue, and the length of stay is then set by that treatment. Patients are fit to fly once the drain is capped, the fever has gone and the bilirubin is falling, in the second week for most. The coordinator arranges a letter for the airline and a supply of dressings and flushes for the journey, and the drain is exchanged at home by any interventional radiology department with the procedure report in hand.

The week

The visit
Day	What happens	Where
Day 1	Consultation, imaging review, blood tests, antibiotics started if cholangitis is present	Clinic
Day 1 or 2	PTBD under sedation, external or internal-external drain, four hours of observation	Interventional radiology, then the ward
Days 2 to 4	Bile clears, bilirubin falls, drain capped, the patient or a companion learns the flushing and the dressing	Ward
Days 4 to 7	Tumor board on the cause, plan for stent, surgery or chemotherapy, fitness to fly	Clinic and hotel
After	Exchange at two to three months here or at home, the same coordinator reachable on WhatsApp	Home

One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number once you are back home. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages, and it arranges the visa invitation letter, airport transfers, daily transport and accommodation near the hospital for the patient and a companion. Halal, vegetarian and diabetic meals, a prayer room on site, and a female physician on request wherever the rota allows.

Cost

One figure, after the file review.

It covers the procedure, sedation, the drain and the bag, antibiotics, the hospital nights and the teaching, and hospitals in this market quote PTBD as a procedure fee with the metal stent, if one is placed, and the later exchanges priced separately, so that a patient who goes on to a stent within the same visit should ask for the two to be quoted together rather than discovering the second on the final bill.

Confirm what the figure includes. Confirm, too, whether a second session to cross the blockage, should the first not succeed, counts as a separate procedure.

References

Nennstiel S, Weber A, Frick G, et al. Drainage-related complications in percutaneous transhepatic biliary drainage. An analysis over 10 years. J Clin Gastroenterol. 2015;49(9):764-770.
Sharaiha RZ, Khan MA, Kamal F, et al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails. A systematic review and meta-analysis. Gastrointest Endosc. 2017;85(5):904-914.
Coelen RJS, Roos E, Wiggers JK, et al. Endoscopic versus percutaneous biliary drainage in patients with resectable perihilar cholangiocarcinoma. A multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol. 2018;3(10):681-690.

Editor's note

Written by the Biruni Hospital medical editorial team. Reviewed by Assistant Professor Yunus Emre AKPINAR, Radiology.

Medically reviewed by

Assistant Professor Yunus Emre AKPINAR

Radiology

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