Percutaneous transhepatic cholangioscopy

INTRODUCTION — 

Biliary obstruction may involve the extra- or intra-hepatic bile ducts and may be related to nonmalignant (eg, bile duct stones) or malignant (eg, pancreaticobiliary cancer) causes (figure 1). Patients usually present with jaundice, abdominal pain, pruritus, and/or cholangitis. There are several options for treating biliary obstruction including endoscopic intervention, percutaneous transhepatic intervention, and surgery.

Cholangioscopy involves the use of a small diameter endoscope to visualize the common bile duct directly in patients with biliary stones (eg, impacted stones, impacted stone/basket complex) or with biliary strictures. Cholangioscopy is most often performed during endoscopic retrograde cholangiopancreatography (ERCP) using a digital, single-operator cholangioscope (eg, SpyGlass DS) by advancing it through the accessory channel of a duodenoscope. An alternative to peroral cholangioscopy is percutaneous transhepatic cholangioscopy (figure 2). The percutaneous approach is generally reserved for patients with post-surgical anatomy (eg, Roux-en-Y gastric bypass surgery, pancreaticoduodenectomy) or for patients with peripheral bile duct stones because it is more invasive and complex than an ERCP-guided approach.

This topic will discuss patient preparation, technique, postprocedure care, and adverse events related to percutaneous transhepatic cholangioscopy.  

Other approaches to examining the biliary system and performing biliary interventions are discussed separately:

●ERCP – (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

●Peroral cholangioscopy and pancreatoscopy – (See "Cholangioscopy and pancreatoscopy".)

●Percutaneous transhepatic cholangiography – (See "Percutaneous transhepatic cholangiography in adults".)

PATIENT SELECTION

Clinical applications

Diagnostic role — Percutaneous transhepatic cholangioscopy may assist in the evaluation of indeterminate bile duct strictures and for tumor staging. Percutaneous cholangioscopy may also be useful if other imaging examinations (eg, endoscopic retrograde cholangiopancreatography [ERCP] computed tomography [CT], magnetic resonance cholangiopancreatography) are equivocal or inconclusive [1-4]. Cholangioscopy may complement other imaging methods by providing direct visualization of the biliary tree (picture 1).

During cholangioscopy, we inspect the lesion and surrounding mucosa with white light and with narrow band imaging, which is a high-resolution technique that enhances the fine mucosal structure and surface vascular pattern [5]. Cholangioscopy-guided tissue sampling with biopsies or brush cytology achieves high diagnostic yield. In a study including 111 patients with bile duct carcinoma who underwent percutaneous cholangioscopy with biopsy, tissue sampling was positive in 101 patients (96 percent), whereas 10 patients with diffusely infiltrating cholangiocarcinoma had negative biopsies [3]. (See "Clinical manifestations and diagnosis of cholangiocarcinoma".)

Therapeutic interventions — We may use percutaneous cholangioscopy for treating intrahepatic or bile duct stones that are complicated by recurrent pyogenic cholangitis or that could not be removed using peroral methods (ie, ERCP with cholangioscopy). Other indications include passage of a drainage catheter through a high-grade stricture and retrieval of a broken biliary endoprosthesis (picture 2) [6]. (See "Recurrent pyogenic cholangitis".)

Bile duct or intrahepatic stones — We may use percutaneous transhepatic cholangioscopy for patients with suspected bile duct or intrahepatic stones when initial endoscopic interventions are not successful or feasible (eg, patients with postsurgical small bowel anatomy):

●Bile duct stones – During percutaneous cholangioscopy, we may use lithotripsy to fragment bile duct stones that are large (eg, >2 cm) or impacted in the bile duct (picture 3). Methods for performing lithotripsy are discussed separately:

•Mechanical lithotripsy – (See "Endoscopic management of bile duct stones", section on 'Mechanical lithotripsy'.)

•Electrohydraulic lithotripsy – (See "Managing bile duct and pancreatic duct stones with electrohydraulic lithotripsy (EHL)".)

•Laser lithotripsy – (See "Laser lithotripsy for the treatment of bile duct stones".)

Reported rates of common bile duct clearance with percutaneous cholangioscopy have exceeded 90 percent [7-12]. In a series of 25 patients with complex biliary stones, percutaneous transhepatic cholangioscopy plus laser lithotripsy was associated with complete ductal clearance in 24 patients (96 percent). Adverse events were minor and included fever and chills in six patients (24 percent) and mild bleeding from the bile duct wall in one patient (4 percent) [9].

●Intrahepatic stones (hepatolithiasis) – Limited data suggested that percutaneous cholangioscopy was effective for clearing intrahepatic stones in most patients but the recurrence rate was high [13-15]. In an observational study including 245 patients with intrahepatic stones who were followed for a mean of 10 years, percutaneous transhepatic cholangioscopy-guided therapy was associated with complete stone removal in 209 patients (85 percent) and with a stone recurrence rate of 63 percent [15]. In a study including 92 patients with intrahepatic stones who were followed for a median of 42 months, percutaneous cholangioscopy-guided therapy was associated with complete stone clearance in 74 patients (80 percent) [14]. Patients with severe intrahepatic strictures had higher rates of unsuccessful initial clearance compared with patients with a nonsevere stricture or no stricture (42 versus 15 and 0 percent, respectively). In addition, patients with severe intrahepatic strictures had higher rates of recurrent stone disease (100 versus 28 percent) compared with those without severe stricture.

Other interventions — Other therapeutic applications for percutaneous cholangioscopy include dilation of benign bilioenteric strictures, facilitation of endoscopic sphincterotomy, and treatment of bile duct malignancies with laser therapy, radiofrequency ablation, and photodynamic therapy [16-22].

Contraindications — Percutaneous transhepatic cholangioscopy is usually contraindicated when the risk of adverse events is high, and thus, the risks outweigh the potential benefits of the intervention. Relative contraindications to percutaneous transhepatic cholangioscopy include [23]:

●Patients who cannot tolerate moderate sedation, monitored anesthesia care, or general anesthesia.

●Hemodynamic instability.

●Ascites – Large volume ascites is a risk factor for procedural technical difficulty due to ascites displacing the liver.

●Nondilated biliary ducts – Percutaneous access may be technically limited in patients with nondilated bile ducts.

●Untreated biliary tract infection.

●Patients with untreated hemostatic disorders who are deemed to be at high risk for bleeding by the interventionalist. The decision to proceed with percutaneous cholangioscopy in patients with hemostatic disorders is individualized and informed by severity of coagulopathy, severity of underlying disease, procedure-related bleeding risk, and alternatives to the procedure.

PREPROCEDURE EVALUATION — 

The diagnosis of a hepatobiliary biliary disorder is often suspected based on presenting symptoms (abdominal pain, jaundice), laboratory studies, and imaging. Prior to percutaneous cholangioscopy, we review the following:

●Laboratory testing – Complete blood count, liver enzymes (aspartate aminotransferase, alanine aminotransferase), alkaline phosphatase, total bilirubin, and international normalized ratio (INR).

●Imaging – Prior to referral for cholangioscopy, most patients will have had imaging (eg, transabdominal ultrasound, magnetic resonance cholangiopancreatography, computed tomography [CT]) that demonstrates dilated bile ducts. We also review prior imaging to assess the hepatobiliary anatomy.

PATIENT PREPARATION

Adjusting medications — The management of anticoagulants and antiplatelet agents for patients undergoing percutaneous cholangiography is informed by the patient's risk of thromboembolic complications in the absence of therapy and the procedure-related bleeding risk. Our approach to medication adjustments for percutaneous cholangioscopy is similar to the approach for other invasive procedures:

●Anticoagulants – We discontinue warfarin five days before the procedure and restart warfarin on the day after the procedure. We typically discontinue direct oral anticoagulants (DOACs; eg, rivaroxaban, apixaban) one day (ie, 24 hours) before the procedure and restart DOACs on the day after the procedure. (See "Perioperative management of patients receiving anticoagulants".)

●Antiplatelet agents – We discontinue aspirin and other antiplatelet agents (eg, clopidogrel) five days prior to the procedure. We restart antiplatelet agents on the day after the procedure. (See "Perioperative medication management", section on 'Medications affecting hemostasis'.)

When adjusting these medications, we also consult with the clinician managing the patient's long-term anticoagulation (eg, cardiologist, neurologist).

Dietary restrictions — We advise patients to take nothing by mouth for eight hours prior to the procedure, although published evidence supporting this fasting interval is lacking. (See "Preoperative fasting in adults".)

Antibiotic prophylaxis — We administer antibiotic prophylaxis to all patients undergoing percutaneous cholangioscopy. The antibiotic regimens in this setting are similar to those used for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) who require antibiotic prophylaxis (table 1). (See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures".)

Use of antibiotic prophylaxis with percutaneous cholangioscopy is supported by clinical experience and by indirect evidence from studies involving ERCP-guided cholangioscopy. In an observational study including 206 patients with biliary disease who underwent ERCP-guided cholangioscopy, antibiotic prophylaxis was associated with lower rates of postprocedure cholangitis compared with no prophylaxis (1 versus 13 percent) [24].

Sedation/anesthesia — We typically perform percutaneous cholangioscopy with anesthesia services using moderate sedation or monitored anesthesia care in addition to subcutaneous injection of a local anesthetic for the initial procedure. However, the approach to anesthetic management may vary among endoscopists, interventional radiologists, and institutions, and it is also informed by risk for airway difficulty, expected procedure duration, and the patient's hemodynamic status and comorbidities. (See "Gastrointestinal endoscopy in adults: Procedural sedation administered by endoscopists".)

Issues related to use of anesthesia outside the operating room, including the administration of local anesthetics, are discussed separately:

●(See "Considerations for non-operating room anesthesia (NORA)".)

●(See "Monitored anesthesia care in adults".)

●(See "Subcutaneous infiltration of local anesthetics".)

PROCEDURE

Establishing biliary access — Prior to percutaneous transhepatic cholangioscopy, the first step is preprocedural imaging followed by the creation of a cutaneous biliary tract (or cutaneobiliary fistula). An interventional radiologist establishes percutaneous access to the biliary tree using ultrasound and/or fluoroscopic guidance [25]. The fistula tract usually requires a minimum of 7 to 10 days to mature and sequential dilation to a diameter of 12 to 16 French before proceeding with percutaneous cholangioscopy (picture 4) [26,27].

We typically place a biliary catheter for initial drainage prior to percutaneous cholangioscopy. Allowing the fistula tract to mature may also lower the risk of procedure-related bleeding and infection related to biliary leakage [10].

Percutaneous cholangioscopy is time-consuming (procedures can take up to 90 minutes) and requires a well-trained team of an endoscopist and/or interventional radiologist skilled in this exam along with assisting technicians. Thus, it is only available in relatively few tertiary referral centers worldwide.

Equipment — Percutaneous cholangioscopes are available as digital or fiberoptic endoscopes and specific features include:

●Dimensions – Percutaneous cholangioscopes are shorter and wider (length 380 to 730 mm, external diameter 3.5 to 4.9 mm) than the peroral instruments (picture 5). The ratio of external diameter to length allows for better scope control compared with peroral cholangioscopes. In addition, the tip of the scope can be deflected up or down.

●Accessory channel – Percutaneous cholangioscopes have an accessory channel that is 1.2 to 2.2 mm in diameter and permits passage of catheters, biopsy forceps, and brushes [28]. We may also use the accessory channel to pass instruments for lithotripsy or for tumor ablation therapy.

●Optical imaging – Cholangioscopes visualize the mucosal surface using white light or narrow-band imaging (NBI). NBI provides enhanced imaging of certain features, such as mucosal structures and microvasculature [5,29].

●Reprocessing methods – Percutaneous cholangioscopy is performed under sterile conditions, and reprocessing the cholangioscope involves instrument sterilization. These reprocessing methods differ from those for peroral gastrointestinal endoscopes that require high-level decontamination. (See "Preventing infection transmitted by gastrointestinal endoscopy", section on 'Overview of endoscope reprocessing'.)

Single-use endoscopes for biliary endoscopy (if available) may be a reasonable alternative to reusable cholangioscopes [30].

Cholangioscopy technique — The procedural technique for percutaneous cholangioscopy is summarized as follows (figure 2) [10,25]:

●Prior to inserting the cholangioscope, identify the biliary drainage catheter that had been previously placed through the cutaneobiliary fistula. (See 'Establishing biliary access' above.)

●Perform cholangiogram to confirm catheter location.

●Insert a guidewire through the biliary catheter.

●Remove the biliary catheter, leaving the guidewire in place.

●Using fluoroscopic guidance, advance a large bore sheath over the guidewire and to the level of the ampulla of Vater (or the bilioenteric anastomosis in patients with surgically altered anatomy).

●Advance the tip of the guidewire into the small bowel lumen.

●Remove the biliary catheter.

●Advance the cholangioscope alongside the guidewire into the biliary tree under direct visualization. Alternatively, if a stricture is present or if there has not been sufficient time for a mature cutaneobiliary fistula to form, advance the cholangioscope over the guidewire after backloading the guidewire through the biopsy channel of the scope [10].  

●Advance the cholangioscope to the lesion of interest.

●Inspect the lesion of interest and the proximal bile duct system.

●Perform biopsy or therapeutic intervention as indicated (eg, lithotripsy, stone removal).

●Following cholangioscopic examination and/or intervention, reinsert the transhepatic drainage catheter to decompress the biliary system and prevent the fistula from closing. The drainage catheter remains in place until the biliary infection resolves, biliary obstruction is controlled (eg, stone removal, stent placement), and total bilirubin normalizes.

POST-PROCEDURE CARE — 

After the procedure, patients are recovered from sedation or anesthesia. Post-anesthetic care is discussed in detail separately. (See "Overview of post-anesthetic care for adult patients".)

Patients are typically observed in the hospital overnight. If there are no signs of adverse events (eg, bleeding), patients may resume their normal diet on the day after the procedure.

ADVERSE EVENTS — 

Percutaneous transhepatic cholangioscopy is generally regarded as a safe procedure, but adverse events can occur even when standard infection control measures and good technique are used. Reported overall rates of adverse events in patients who undergo percutaneous transhepatic cholangioscopy have varied widely, with a median rate of approximately 20 percent [1,10,23,31-33]. Adverse events may be related to the creation of the cutaneobiliary fistula, the cholangioscopic examination, or cholangioscopy-guided interventions (eg, biliary drainage). Specific events include cholangitis, bleeding, pancreatitis, bile duct injury, and catheter-related issues (eg, catheter migration or obstruction).

Studies suggested that adverse events may be more often related to initial creation of the cutaneous fistula and tract dilation than to cholangioscopy. In a study of 364 patients in whom biliary access was established with a fistula tract, adverse events occurred in 47 patients (13 percent) [32]. However, adverse events related to percutaneous cholangioscopy were reported during 58 of 848 procedures (7 percent).

Management of specific adverse events includes [10]:

●Bleeding – Although friable bile ducts may bleed with manipulation from the cholangioscope or other instruments, bleeding is usually limited and does not result in hemodynamic instability. When such bleeding occurs, it may impair visualization. We manage this by irrigating the bile ducts. If visualization remains limited, we terminate the procedure and place a biliary drainage catheter with plans to repeat the procedure in two to four weeks.

●Cholangitis – Cholangitis is a major infectious complication of percutaneous cholangioscopy and related interventions, with reported rates ranging from 6 to 14 percent of procedures [28,34]. The management of cholangitis includes decompression of the obstructed bile ducts and antimicrobial therapy, and these issues are discussed separately. (See "Acute cholangitis: Clinical manifestations, diagnosis, and management", section on 'Management'.)

●Pancreatitis – The management of post-cholangioscopy pancreatitis is the same as that for acute pancreatitis from other causes, and this is discussed in detail separately. (See "Management of acute pancreatitis".)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Biliary infection and obstruction".)

SUMMARY AND RECOMMENDATIONS

●Background – Percutaneous transhepatic cholangioscopy is an interventional procedure that involves establishing percutaneous access to the biliary tract. A small diameter endoscope is used to visualize the biliary tree and to perform interventions such as removal of intrahepatic stones or placement of a biliary drainage catheter through a stricture (figure 2). (See 'Introduction' above.)

Percutaneous transhepatic cholangioscopy is generally reserved for patients with difficult biliary access due to post-surgical anatomy (eg, Roux-en-Y gastric bypass surgery, pancreaticoduodenectomy) or for patients with peripheral bile duct stones. (See 'Clinical applications' above.)

●Preprocedure evaluation – The diagnosis of a hepatobiliary disorder is often suspected based on presenting symptoms (abdominal pain, jaundice), laboratory studies, and imaging. Prior to percutaneous cholangioscopy, we review the following:

•Laboratory testing – Complete blood count, liver enzymes (aspartate aminotransferase, alanine aminotransferase), alkaline phosphatase, total bilirubin, and international normalized ratio (INR).

•Imaging – Prior to referral for cholangioscopy, most patients will have had imaging (eg, transabdominal ultrasound, magnetic resonance cholangiopancreatography, computed tomography [CT]). Prior imaging studies are reviewed to assess hepatobiliary anatomy.

●Patient preparation

•Adjusting medications – Our approach to medication adjustments for percutaneous cholangioscopy includes:

-Anticoagulants: We discontinue warfarin five days before the procedure and restart warfarin on the day after the procedure. We typically discontinue direct oral anticoagulants (DOACs) one day (ie, 24 hours) before the procedure and restart DOACs on the day after the procedure. (See "Perioperative management of patients receiving anticoagulants".)

-Antiplatelet agents: We discontinue aspirin and other antiplatelet agents (eg, clopidogrel) five days prior to the procedure. We restart antiplatelet agents on the day after the procedure. (See "Perioperative medication management", section on 'Medications affecting hemostasis'.)

When adjusting these medications, we also consult with the clinician managing the patient's long-term anticoagulation (eg, cardiologist, neurologist).

•Antibiotic prophylaxis – We suggest using antibiotic prophylaxis for all patients undergoing percutaneous cholangioscopy (Grade 2C). The antibiotic regimens are similar to those used for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) who require antibiotic prophylaxis (table 1). (See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures".)

●Procedure – Prior to percutaneous cholangioscopy, an interventional radiologist establishes percutaneous access to the biliary tree using imaging guidance. After the fistula tract matures and undergoes sequential dilation, we perform percutaneous cholangioscopy by advancing the cholangioscope over a wire under fluoroscopic guidance until the target lesion is reached. We examine the lesion of interest and perform biopsy or therapeutic intervention (eg, stone removal) as indicated. (See 'Procedure' above.)

●Postprocedure care – After the procedure, patients are recovered from sedation or anesthesia. Post-anesthetic care is discussed in detail separately. (See "Overview of post-anesthetic care for adult patients".)

Patients are typically observed in the hospital overnight. If there are no signs of adverse events (eg, bleeding), patients may resume their normal diet on the day after the procedure. (See 'Post-procedure care' above.)

●Adverse events – Percutaneous transhepatic cholangioscopy is generally regarded as a safe procedure, but adverse events can occur even when standard infection control measures and good technique are used. Adverse events may be related to the creation of the cutaneobiliary fistula, the cholangioscopic examination, or cholangioscopy-guided interventions (eg, biliary drainage). Specific events include cholangitis, bleeding, bile duct injury, pancreatitis, and catheter-related issues (eg, catheter migration or obstruction). (See 'Adverse events' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Osamu Togawa, MD, who contributed to an earlier version of this topic review.