Percutaneous transhepatic biliary drainage relieves obstructive jaundice from above, through the liver, when the standard endoscopic route isn't possible or hasn't succeeded.
Obstructive jaundice occurs when a blockage somewhere along the bile duct system prevents bile — the fluid produced by the liver to help digest fat and carry away waste products — from draining normally into the bowel. Bile then backs up into the liver and bloodstream, causing yellowing of the skin and eyes (jaundice), dark urine, pale stools, and often intense itching. If the trapped bile becomes infected — a condition called cholangitis — the situation can progress quickly to severe sepsis, making it a genuine medical emergency requiring urgent decompression.
The most common cause of obstructive jaundice requiring intervention is a tumour — most often pancreatic cancer, bile duct cancer (cholangiocarcinoma), gallbladder cancer, or cancer that has spread to the liver or the lymph nodes around the bile duct from elsewhere in the body — pressing on or growing into the bile duct and blocking it. Less commonly, obstruction results from a benign stricture (scarring, often related to previous surgery or inflammation) or a retained gallstone. Whatever the cause, relieving the blockage promptly is important both for symptom relief and to protect liver function.
Difficult to reach and stent adequately via ERCP.
Previous surgery has changed the stomach and bowel anatomy, preventing the endoscope reaching the right position.
An ERCP attempt has already failed to cross the blockage.
A fine needle is passed through the skin and liver into a bile duct under local anaesthesia with sedation.
Contrast dye and X-ray map the biliary system and show exactly where the blockage is.
A catheter, and often a permanent stent, restores internal bile drainage into the bowel.
Most patients are admitted for a period of observation afterward.
Endoscopic retrograde cholangiopancreatography (ERCP) — draining the bile duct from below, via an endoscope passed through the mouth and stomach — is the standard, first-line treatment for most causes of obstructive jaundice, and is generally attempted first wherever feasible. Percutaneous transhepatic biliary drainage becomes the preferred route specifically when ERCP isn't possible or hasn't succeeded — for instance, where the tumour or blockage is high up near the liver (a hilar or proximal obstruction, which can be technically difficult to reach and stent adequately via ERCP), where previous surgery has altered the anatomy of the stomach and bowel in a way that prevents the endoscope reaching the right position, or where an ERCP attempt has already failed to cross the blockage.
PTBD approaches the problem from the opposite direction — from above, through the liver — which is precisely why it can succeed in many situations where the endoscopic route can't. Some published series have found percutaneous approaches achieve technical success even in situations where prior endoscopic drainage has failed, making PTBD an important and sometimes essential fallback rather than a lesser alternative.
Planning: prior CT, MRI, or ultrasound imaging is reviewed to understand exactly where the blockage is and which bile ducts within the liver are dilated and need draining.
Access: under local anaesthesia with sedation, a fine needle is passed through the skin and liver into a bile duct, guided by ultrasound and confirmed with contrast dye and X-ray (a cholangiogram), which maps the biliary system and shows exactly where the blockage is.
Drainage: a guidewire and catheter are advanced through the blockage where possible, and a drainage tube is left in place — either draining externally into a bag, internally past the blockage into the bowel, or a combination of both, depending on whether the wire and catheter can be advanced all the way across the obstruction at that first sitting.
Stenting: once the bile ducts have had a period to drain and the patient's condition has improved, a permanent, self-expanding metal or plastic stent can often be placed across the blockage — either in the same session or, more commonly, a few days later once bile has been adequately decompressed — restoring internal drainage into the bowel, sometimes allowing the external catheter to eventually be removed.
The initial drainage procedure typically takes 30 to 60 minutes, and most patients are admitted for a period of observation afterward, since the priority immediately following the procedure is monitoring for early complications and confirming the drain is functioning well.
If an external drainage bag is needed, at least initially, the treating team will explain how to care for it — keeping the site clean, monitoring the drainage volume and colour, and flushing the tube periodically to prevent blockage. Blood tests are checked regularly afterward to confirm that bilirubin and liver function are improving as the obstruction is relieved. Where an internal stent has been placed and is draining well, the external portion of the drain may be capped or removed over subsequent visits, once the team is confident the stent alone is providing adequate drainage. For some patients — particularly where the underlying cancer isn't curable — the goal of treatment is durable symptom relief and improved quality of life, sometimes also lowering bilirubin enough to allow chemotherapy to be safely restarted or continued.
PTBD is a well-established, generally safe procedure, though as with any biliary intervention, recognised risks include bleeding, infection or worsening of cholangitis immediately after the procedure (which is why patients are typically covered with antibiotics and monitored closely in the days afterward), bile leakage, and, uncommonly, injury to a nearby structure during the needle pass through the liver. Because the procedure is often performed in patients who are already unwell from their underlying condition, risk is assessed individually, and a structured approach to patient selection and close post-procedure monitoring meaningfully improves safety.
Managing obstructive jaundice well depends on close coordination between gastroenterology (who typically attempt ERCP first, where appropriate), interventional radiology (who perform PTBD when the endoscopic route isn't suitable or has failed), oncology (for patients with an underlying cancer), and hepatology, since the right approach, and the right sequencing between endoscopic and percutaneous techniques, depends on the specific cause and anatomy of the blockage in each patient. This is why biliary drainage decisions are best made as part of a coordinated pathway between these specialties rather than a single, standalone procedure.
ERCP is generally tried first, but PTBD is used when ERCP isn't possible or hasn't succeeded — for example, if the blockage is high up near the liver, if previous surgery has altered the anatomy, or if an ERCP attempt has already failed to get past the obstruction.
Not necessarily — once the bile ducts have drained and a permanent internal stent is placed and working well, the external portion of the drain can often be capped or removed. Some patients do need longer-term external drainage, depending on their specific situation.
It's done under local anaesthesia with sedation, so it's generally well tolerated, with some soreness at the site afterward. Most patients are kept in hospital for a period of observation and pain relief following the procedure.
The most common cause requiring this kind of intervention is a tumour — pancreatic, bile duct, or gallbladder cancer, or cancer that has spread to the liver or surrounding lymph nodes — though benign strictures and gallstones can also cause blockage.
An untreated blockage can cause worsening liver dysfunction, and if the trapped bile becomes infected (cholangitis), it can progress quickly to severe, life-threatening sepsis — which is why prompt treatment is important.
Book a consultation with Dr. Giragani, or send your scans for a specialist second opinion.