Percutaneous Transhepatic Cholangiogram And Biliary Drain Placement Technique and Dictation

PROCEDURES:

1. Percutaneous Transhepatic Cholangiogram
2. Internal/External Biliary Drainage Catheter Placement

DATE:

INDICATION: __-year-old female with newly diagnosed pancreatic head mass and biliary obstruction.

OPERATORS: John Doe, MD (Attending)/Jane Doe, MD (Fellow)    

CATHETER: 8 French internal/external biliary drain

MEDICATIONS: Fentanyl 400 mcg IV, Versed 2 mg IV, Zofran 4 mg IV, aztreonam 1 g IV vancomycin 1 g IV.   

FLUOROSCOPY TIME: 29.3 minutes

CONTRAST: 30 mL nonionic contrast

PROCEDURE:

The risks, benefits, and alternatives to the procedure and sedation were explained to the patient . The specific risks of bleeding, infection including life-threatening sepsis, and damage to structures within the liver were discussed and accepted. Informed consent was obtained. A timeout was performed prior to beginning the procedure.

Ultrasonographic evaluation was carried out. The anterior abdominal wall and right flank were prepped and draped in standard sterile fashion.  An appropriate skin entry site was identified using fluoroscopy and ultrasound, and anesthetized with local.  Under fluoroscopic guidance, a 22G Chiba needle was advanced into the liver and PTC performed in standard fashion.  A  bile duct was entered and the biliary system was opacified with contrast.  Cholangiographic images were obtained.

A suitable duct for drain placement was identified on the right. Under direct fluoroscopic guidance, a posterior right duct was accessed with a second 21-gauge AccuStick needle.  A 0.018″ wire was passed centrally, and the needle exchanged for a 6 French transitional catheter.  The inner stiffener, dilator, and guidewire were removed and contrast was injected to confirm location.  A 0.035″ glidewire and 4 French catheter were negotiated across the distal common bile duct obstruction into the small bowel. The glidewire was removed and contrast was injected to confirm location.  A 0.035″ Amplatz wire was placed through the catheter.  The catheter was removed and the tract was dilated to 9 French.  Finally, a(n) 8 French internal-external biliary drain was placed over the wire. The Cope loop was formed and locked in the duodenum. The side holes were positioned above the level of obstruction. Contrast was injected to confirm location. The catheter was secured to the skin with 2-0 Ethilon and attached to gravity drainage.  A sterile dressing was applied.

The procedure was well tolerated, and the patient discharged from the angiography suite in satisfactory condition.

FINDINGS:  A CT scan from field a was reviewed

1. Cholangiography shows  demonstrates moderate dilation of the central and common bile duct with a high-grade obstruction of the distal common bile duct corresponding to the region of the patient’s known pancreatic mass. 
2. After catheter placement, the internal/external drain enters a posterior right hepatic duct. The Cope loop is in the duodenum.

IMPRESSION:

1. Moderate dilation of the central intrahepatic and common bile duct. There is a high-grade obstruction of the distal common bile duct.
2. Successful placement of 8 French internal/external biliary drain via a peripheral right duct.