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Percutaneous transhepatic cholangioscopy

Percutaneous transhepatic cholangioscopy
Literature review current through: May 2024.
This topic last updated: Aug 09, 2023.

INTRODUCTION — Miniature intraductal endoscopes have an important role in the diagnosis and nonsurgical treatment of biliary diseases, complementing diagnostic imaging modalities such as computed tomography and magnetic resonance imaging by permitting direct visualization of the biliary tree.

Intraductal endoscopes can be used intraoperatively and during endoscopic retrograde cholangiopancreatography. In addition, intraductal endoscopes may be introduced into the biliary tree via a percutaneous transhepatic approach.

This topic will review percutaneous transhepatic cholangioscopy, which is most commonly used when anatomic considerations prohibit a peroral approach (eg, after previous Roux-en-Y gastric bypass surgery) [1-3]. Percutaneous transhepatic cholangiography and peroral cholangioscopy and pancreatoscopy are discussed separately. (See "Percutaneous transhepatic cholangiography in adults" and "Cholangioscopy and pancreatoscopy".)

PROCEDURE — The first step in percutaneous transhepatic cholangioscopy (PTCS) is the creation of a cutaneobiliary fistula. Percutaneous access to the biliary tree is typically obtained by interventional radiology under ultrasound and fluoroscopic guidance. Once the fistula tract matures, usually after 7 to 10 days, and has been sequentially dilated to at least 12 to 16 French, PTCS can be performed (picture 1) [4,5].

PTCS 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.

Instruments — Percutaneous cholangioscopes are specialty fiberoptic endoscopes unlike the peroral cholangioscopes that are used during endoscopic retrograde cholangiopancreatography (ERCP), which are videoscopes. Percutaneous cholangioscopes are also shorter and wider (length 380 to 450 mm, external diameter 4.1 to 4.9 mm) than the peroral instruments (picture 2). The ratio of external diameter to length allows for better scope control compared with the peroral scope used during ERCP. In addition, the tip of the scope can be deflected up-down.

Percutaneous cholangioscopes have a biopsy channel of 1.7 to 2.2 mm in diameter that permits passage of catheters, biopsy forceps, and brushes. Therapeutic instruments for electrohydraulic lithotripsy and tumor ablation therapy can also be passed through the channel.

Narrow-band imaging (NBI) provides enhanced imaging of certain features, such as mucosal structures and microvasculature [6]. While it is available in peroral video cholangioscopes (CHF-B260/BP260), it is not currently available in percutaneous cholangioscopes. However, one study reported using a peroral video cholangioscope with NBI through a percutaneous route [7].

Preparation — Patients should fast for at least eight hours prior to the procedure, and antibiotic prophylaxis is routinely administered using the same agents that are given prior to ERCP in patients with biliary obstruction (table 1). The procedure is usually performed under moderate sedation. (See "Gastrointestinal endoscopy in adults: Procedural sedation administered by endoscopists".)

While standard gastrointestinal endoscopes used perorally only need to undergo high-level decontamination, the percutaneous cholangioscope must be sterilized and handled under sterile conditions [8].

Technique — Prior to cholangioscope insertion, a percutaneous transhepatic drainage catheter is placed through the cutaneobiliary fistula. A guidewire is then inserted and advanced to the ampulla of Vater or the bilioenteric anastomosis under fluoroscopic guidance. Once the tip of the guidewire is in the small bowel lumen, the catheter is removed.

The cholangioscope is advanced alongside the guidewire into the biliary tree under direct visualization in most cases. Alternatively, if a stricture is present or if there has not been sufficient time for a mature cutaneobiliary fistula to form, the cholangioscope is advanced over the guidewire after backloading the guidewire through the biopsy channel of the scope. During the procedure, the biopsy channel is continuously rinsed with sterile normal saline. To prevent cholangitis due to cholangiovenous reflux, it is important to maintain biliary tract pressure as low as possible since cholangiovenous reflux of bacteria occurs with pressures greater than 30 cm H2O [9]. In the absence of obstruction, the guidewire is followed until the cholangioscope reaches the lesion of interest, the papilla of Vater, or the bilioenteric anastomosis. Once the papilla of Vater or the bilioenteric anastomosis is reached, the proximal bile duct system can also be inspected. At the end of the examination, the transhepatic drainage catheter is usually reinserted to drain the biliary system and to prevent the fistula from closing.

CLINICAL APPLICATIONS — Percutaneous transhepatic cholangioscopy (PTCS) has both diagnostic and therapeutic applications. Diagnostic PTCS assists in the differentiation of benign from malignant bile duct strictures and in the preoperative staging of bile duct carcinoma. It can also help clarify nonspecific findings on other imaging procedures such as endoscopic retrograde cholangiopancreatography (ERCP), computed tomography, percutaneous cholangiography, and magnetic resonance cholangiopancreatography (MRCP).

Therapeutic PTCS is commonly performed to treat complicated cholangiolithiasis (eg, recurrent pyogenic cholangitis) or cholangiolithiasis in patients who have failed or are not candidates for ERCP. Other indications include the passage of a drainage catheter through a high-grade stricture and retrieval of a broken biliary endoprosthesis (picture 3) [10]. (See "Recurrent pyogenic cholangitis".)

Diagnostic cholangioscopy — The role of PTCS in the diagnosis of bile duct and pancreatic carcinoma has been described by several groups [11-19]. In addition to visual inspection, the procedure permits tissue sampling with biopsies or brush cytology. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Diagnostic approach'.)

Illustrative studies have shown the following:

One study included 385 patients with biliary or pancreatic malignancies [13]. A total of 328 biopsies were obtained that detected malignancy in 82 percent of cases. When histopathologic examination or clinical course was used as the gold standard, PTCS had an accuracy of 96 percent in patients with bile duct carcinoma and 67 percent in those with pancreatic cancer (table 2).

In a second report, 46 of 52 patients (88 percent) were correctly diagnosed as having malignancy with PTCS, using histopathologic examination or clinical course as the gold standard [8]. False-negative results were observed in six patients (12 percent).

A study comparing PTCS with MRCP included 99 patients with hilar cholangiocarcinoma who underwent both tests [19]. The overall agreement between the two tests with regard to tumor extension was 88 percent, though PTCS appeared to be more accurate for the characterization of polypoid or diffuse sclerosing lesions.

The sensitivity of a single biopsy for detecting invasive carcinoma is low due to the superficial nature of the biopsies, but it increases if multiple biopsies are taken (up to 91 percent in one study) [18]. Some authorities recommend a combination of PTCS and intraductal ultrasonography to obtain a more accurate assessment of intramural spread [14,18]. (See "Intraductal ultrasound for evaluating the pancreaticobiliary ductal system".)

Therapeutic cholangioscopy — The largest experience with therapeutic cholangioscopy has been for the treatment of complicated bile duct stones that are not amenable to ERCP [18,20-24]. Although long-term follow-up is limited, PTCS appears to be an effective and safe method to treat complicated intra- and extrahepatic bile duct stones.

Choledocholithiasis — Complicated bile duct stones can be treated by combining PTCS with lithotripsy. In one series, 50 patients with difficult bile duct stones were treated with electrohydraulic lithotripsy under PTCS control [20]. Complete bile duct clearance was achieved in 46 of the patients (92 percent). Severe complications related to the rapid dilation of the cutaneobiliary fistula occurred in 11 cases. Other groups have reported similar experiences [8].

PTCS has also been combined with a pulsed dye laser for lithotripsy. In one study of PTCS with laser lithotripsy, stone fragmentation was successful in 12 of 13 patients (92 percent) [25]. The stone fragments passed spontaneously in two patients. When sphincterotomy and stent insertion were added to the procedure, the success rate for stone removal increased to 100 percent. Bleeding occurred in two of the patients. (See "Laser lithotripsy for the treatment of bile duct stones".)

Another group reported success in 24 of 25 patients (96 percent) with complicated bile duct stones using laser lithotripsy with a small-caliber cholangioscope (3.4 mm) [26]. Only minor complications occurred, including chills and fever in six patients and mild hemorrhage in one patient.

Intrahepatic stones — PTCS results in high initial success rates for the treatment of intrahepatic stones, but recurrence is seen in up to one-third of patients.

Illustrative studies have shown the following:

One study included 165 patients with intrahepatic stones treated by PTCS who were followed for up to five years [27]. Complete stone removal was achieved in 80 percent, with a recurrence rate following successful stone removal of 33 percent.

Another report included 92 patients, 68 of whom were followed for a median of 42 months [28]. Complete clearance of stones was achieved in 74 patients (80 percent). The rate of complete clearance was significantly lower in those with severe intrahepatic strictures compared with those without or with mild to moderate strictures. Patients with severe intrahepatic strictures also had a higher recurrence rate compared with those without or with mild to moderate strictures (100 versus 28 percent).

The influence of treatment with PTCS on the natural history of intrahepatic stones and survival is uncertain. The benefit of extracting intrahepatic stones depends upon the underlying disease and the clinical setting. For example, in the report of 92 patients discussed above, the recurrence rate was significantly higher in patients with advanced biliary cirrhosis (Child class B or C) compared with those without cirrhosis or Child class A cirrhosis (89 versus 29 percent) [28]. Thus, successful clearance of intrahepatic stones by PTCS must be considered in the overall context of the underlying disease and other therapeutic options.

Other applications — Other therapeutic applications for PTCS include dilation of benign bilioenteric strictures, facilitation of endoscopic sphincterotomy, and treatment of bile duct malignancies with laser therapy, photodynamic therapy, and microwave coagulation [29-32].

COMPLICATIONS — Complications related to percutaneous transhepatic cholangioscopy (PTCS) are mostly related to the initial creation of the cutaneobiliary fistula [20,33-35]. Subsequent dilations of the fistula and the cholangioscopy itself are less risky. However, overly rapid dilation has been associated with increased procedure-related mortality.

Reported complications include hemobilia, cholangitis, bacteremia, catheter migration, catheter blockage, and bile duct injuries (including perforation). In one series, complications were observed in 47 of 364 patients (13 percent) who underwent PTCS with biliary drainage [33]. The overall incidence of severe complications was 8 percent, and there were no deaths related to the procedure.

In another series, severe complications occurred in 11 of 50 patients (22 percent) with complicated bile duct stones who had PTCS performed within three days of accessing the biliary system [20]. The complications included hemobilia, requiring transfusion and bile duct perforation, and there were four fatalities. A significant reduction in complications was observed after adopting a protocol whereby the biliary tract was dilated in two sessions three days apart, followed by a waiting period of six days for the tract to mature.

Adequate biliary drainage must be achieved after PTCS to reduce the risk of cholangitis [34], which in one series occurred in 6 percent of patients [35]. Finally, when PTCS is performed for biliary tract malignancy, the possibility of tumor seeding should be taken into consideration [36].

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

Miniature intraductal endoscopes have an increasingly important role in the diagnosis and nonsurgical treatment of biliary and pancreatic diseases, complementing diagnostic imaging modalities such as computed tomography and magnetic resonance imaging. (See 'Introduction' above.)

Diagnostic percutaneous transhepatic cholangioscopy (PTCS) assists in the differentiation of benign from malignant bile duct strictures and in preoperative staging of bile duct carcinoma. It can also help clarify nonspecific findings on other imaging procedures such as endoscopic retrograde cholangiopancreatography (ERCP), computed tomography, percutaneous cholangiography, and magnetic resonance cholangiopancreatography. (See 'Diagnostic cholangioscopy' above.)

Therapeutic PTCS is commonly performed to treat complicated cholangiolithiasis or cholangiolithiasis in patients who have failed or are not candidates for ERCP. (See 'Therapeutic cholangioscopy' above.)

Complications related to PTCS include hemobilia, cholangitis, bacteremia, catheter migration, catheter blockage, and bile duct injuries (including perforation). (See 'Complications' above.)

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

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