PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) FOR CHOLANGIOCARCINOMA

After percutaneous transhepatic cholangiography (PTC), current percutaneous biliary interventions to manage malignant obstruction include biliary drainage (PTBD) and metallic and plastic internal stent insertion. PTC allows the direct opacification of the biliary system and is regarded as the most accurate preoperative diagnostic modality for assessing the longitudinal extension of hilar cholangiocarcinoma (CCA) compared with endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP). After ultrasound (US) and subsequent computed tomography (MDCT) and/or magnetic resonance imaging (MRI), many diagnostic algorithms propose direct cholangiography using endoscopic retrograde cholangiopancreatography (ERCP) or its percutaneous counterpart transhepatic cholangiography (PTC) associated with brush cytology and forceps biopsy for diagnostic confirmation. In most centres, ERCP has largely replaced PTC for diagnostic purposes, and endoscopic stenting is the first-line of therapy. The percutaneous approach is usually employed when the endoscopic approach has either failed or is not possible, as in patients with a history of partial gastrectomy, gastric outlet obstruction or biliary-enteric bypass. The choice between the two approaches mainly depends on proximal or distal tumour location. Patients with hilar strictures are best treated percutaneously, as endoscopic drainage has higher failure and complication rates in this situation. The percutaneous approach can also be used to position biliary drainage (PTBD) for temporary biliary decompression prior to definitive surgery. Preoperative biliary drainage is indicated in patients with cholangitis, long-standing jaundice or poor nutrition, and in surgical candidates in whom liver volume is <40% of total liver volume. Major hepatectomy combined with preoperative PTBD followed by portal vein embolization is a safe management strategy for resectable perihilar CCA. For palliation of malignant obstructive jaundice, PTBD and stenting is a safe and effective technique and is equally successful in the treatment of distal and proximal bile obstruction. In the percutaneous approach, metal self-expandable stents have proved superior to plastic stents and should be preferred. Technical success is >90% and clinical success is >75% in all major series. The vast majority of complications can be treated conservatively and the procedure-related mortality is <2% in most series. About 10–30% of patients will have recurrent jaundice after PTBD or stenting and require re-intervention. Endoscopic stent placement is commonly preferred as the primary tool in distal bile duct strictures and the percutaneous approach is mostly reserved for cases where ERCP fails or is not possible. Patients with hilar strictures involving the right or left hepatic duct (or both) are best treated by percutaneous placement of metallic stents. Intraductal brachytherapy and radiofrequency ablation can be further tools whose efficacy is still under evaluation.