Application Techniques And Complication Prevention Of Chiba Needle in Percutaneous Transhepatic Cholangiography And Biliary Drainage

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Percutaneous transhepatic cholangiography (PTC) and subsequent percutaneous transhepatic biliary drainage (PTCD/PTBD) are important interventional methods for treating obstructive jaundice. The Chiba needle is the preferred initial puncture needle in this procedure - because its fine diameter minimizes the risk of biliary bleeding, bile leakage, and liver laceration.

1. Indications and Contraindications

PTC/PTCD are suitable for: ① unexplained obstructive jaundice requiring differentiation between intrahepatic cholestasis and extrahepatic obstruction; ② preoperative biliary decompression or palliative drainage for malignant biliary obstruction (pancreatic head cancer, cholangiocarcinoma, ampullary cancer, metastatic tumor compression); ③ ERCP failure or inability to perform ERCP; ④ preoperative angiography evaluation before biliary stent placement. Contraindications include: uncorrected coagulation disorders, uncontrolled severe sepsis (unless emergency drainage is needed), infected puncture path, massive ascites, iodine allergy (unless CO₂ is used or angiography is abandoned), uncooperative patients, and congenital biliary atresia (low puncture success rate).

2. Key Points of Chiba Needle Puncture

The patient lies supine or slightly left posterior oblique, with the right arm raised. Ultrasound or fluoroscopy is used to locate the right mid-axillary line at the 7th–9th intercostal space (mostly the 8th intercostal space) and mark the puncture point - always puncture above the upper edge of the rib to avoid the intercostal artery and nerve. Disinfect and drape, and use 2% lidocaine for local anesthesia to the liver capsule. Use a scalpel to make a small ~2 mm skin incision to facilitate needle entry. Hold a 21G or 22G Chiba needle (length 15–20 cm, with or without a disposable stylet), and during the patient's breath-holding at the end of quiet respiration, insert the needle at a 40°–60° angle to the coronal plane toward the right edge of the 11th–12th thoracic vertebra (the xiphoid approach is directed upward and backward to the right toward the porta hepatis). Advance step by step under imaging surveillance: first pass through the abdominal wall and liver capsule, then slowly advance toward the expected intrahepatic bile duct area.

3. Confirming Entry into the Bile Duct and Cholangiography

When the needle tip reaches the expected bile duct plane (usually the right or left peripheral dilated bile duct branch), withdraw the stylet (if present), attach a 5 mL syringe, and slowly aspirate - if golden-yellow or dark green bile flows out, it confirms entry into the bile duct. Alternatively, inject a small amount of diluted non-ionic iodinated contrast agent (e.g., iohexol 300 mgI/mL diluted 1:1), injecting while withdrawing the needle, and seeing a tree-like persistent opacification of the biliary tree confirms entry. Note: Injection pressure should not be too high to prevent infected bile from refluxing into the blood and causing bacteremia/sepsis; when the proximal bile duct is significantly dilated, inject a small amount first for observation.

4. Subsequent Operations - Microwire Introduction and Tract Establishment

After confirming the bile duct, insert a 0.018-inch microwire (hydrophilic coating preferred) through the Chiba needle lumen. It is better if the guidewire smoothly passes through the obstruction into the duodenum; withdraw the Chiba needle while retaining the guidewire, exchange and gradually dilate the puncture tract along the guidewire to an appropriate size (usually 6–8F), and place an external drainage catheter or multi-side-hole internal-external drainage catheter across the obstruction, fix it, and connect to a drainage bag. This "micropuncture technique" (Chiba needle + microwire) significantly reduces the bleeding rate of the first bile duct puncture compared with directly using a thick trocar needle.

5. Complications and Prevention

① Bleeding/biliary bleeding: Most are mild and self-limiting; prevention is better than cure: precise imaging guidance to avoid large hilar vessels, use of fine needles, limiting puncture attempts to ≤3 times; massive bleeding requires interventional embolization. ② Bile leakage/biliary peritonitis: Due to excessively large puncture tract or improper drainage tube position; ensure all side holes of the drainage tube are within the bile duct and drainage is unobstructed. ③ Infection/bacteremia: Broad-spectrum antibiotics 30 minutes before surgery, strict aseptic technique, limited contrast injection, and sufficient postoperative anti-infection treatment. ④ Pneumothorax/hemothorax: Puncture point too high (>7th intercostal space) injuring the pleura; positioning should be at the 8th intercostal space or below. ⑤ Accidental puncture of adjacent organs (colon/stomach): Rare, avoided by path planning.

Summary: The Chiba needle assumes the critical function of "initial bile duct puncture → confirmation → guidewire introduction" in the PTC/PTCD process. Skillful use of its fine-needle characteristics, precise imaging positioning, and standardized breath-holding coordination can make biliary interventional procedures safe, efficient, and with controllable complications. It is a fundamental skill in the diagnosis and treatment of biliary diseases in interventional departments.