ORIGINAL PAPERS
Percutaneous transhepatic cholangiography and drainage and endoscopic
retrograde cholangiopancreatography for hilar cholangiocarcinoma:
which one is preferred?
Jianhong Zhu1, Huang Feng2, Deqing Zhang2, Rui Li2, Jing Li1, Hongwei Peng1, Wen Tang1, Duanmin Hu1,
Wei Wu1, Kewei Hu1, Wei Cai1 and Guojian Yin1
1
Department of Gastroenterology. The Second Affiliated Hospital of Soochow University. Suzhou, Jiangsu. China. 2Department of Gastroenterology.
The First Affiliated Hospital of Soochow University. Suzhou, Jiangsu. China
Received: 19/02/2020  · Accepted: 28/03/2020
Correspondence: Guojian Yin. Department of Gastroenterology. The Second Affiliated Hospital of Soochow University.
215004 Suzhou, Jiangsu. China. e-mail: ygj234@126.com
ABSTRACT
Introduction: both percutaneous transhepatic cholangi-
ography and drainage (PTCD) and endoscopic retrograde
cholangiopancreatography (ERCP) with SEMS implantation
have been used for unresectable hilar cholangiocarcinoma
(HC) in the clinic for many years. However, which one is
preferred is still unknown.
Objective: to study the effects of biliary drainage of self-
expanding metal stents (SEMS) implantation under PTCD
or ERCP to treat HC.
Methods: the clinical data of 82 patients with HC from Janu-
ary 2006 to January 2015 were recorded retrospectively.
Patients were treated with biliary implantation of self-
expanding metal stents (SEMS) under PTCD (PTCD group,
40 patients) or ERCP (ERCP group, 42 patients). Clinical
data, including total bilirubin concentrations, complications
and survival time were analyzed.
Results: the remission of jaundice was similar in both
groups (p > 0.05). The median survival time of the ERCP
group and PTCD group were 237 d and 252 d respectively,
with no significant differences (p > 0.05). The biliary infec-
tion rates under ERCP and PTCD procedure were 52.4 % and
20.0 % respectively, with a significant statistical difference
(p < 0.05). For those HC patients of Bismuth III/IV, the infec-
tion rates under ERCP and PTCD procedure were 58.3 %
and 14.3 %, respectively (p < 0.05).
Author´s contribution: Jianhong Zhu, Deqing Zhang, Rui Li and Huang Feng contributed
equally to this study.
Financial support: National Key R&D Program of China (2017YFC0114300), SS201640,
SS201641, QNRC2016862, and LCZX201707.
REV ESP ENFERM DIG 2020:112(12):893-897
DOI: 10.17235/reed.2020.6937/2020
Conclusions: both PTCD and ERCP with SEMS implantation
were effective to prolong the survival time of HC patients.
The biliary infection rates were higher in the ERCP group,
especially for Bismuth III/IV HC patients.
Keywords: Hilar cholangiocarcinoma. PTCD. ERCP. SEMS.
INTRODUCTION
Hilar cholangiocarcinoma (HC) is a type of bile duct malig-
nant tumor, which constitutes 58-75 % of extrahepatic bile
duct carcinomas and causes malignant biliary obstruction
(1,2). HC has an extremely poor prognosis with a five-year
survival rate less than 10 % (3-5), as it is often diagnosed at
an advanced stage due to their special anatomical location
and atypical symptoms. Palliative treatment is very impor-
tant for unresectable HC patients with extrahepatic obstruc-
tive jaundice (6,7). The majority of unresectable HC patients
should be offered biliary drainage management (8) or palli-
ative surgery (9) in order to decrease the pressure of the bil-
iary system, protect deteriorated liver function and control
recurrent cholangitis. Percutaneous transhepatic cholangi-
ography drainage (PTCD), with or without biliary implan-
tation of metal stents (MS), has been applied in the clinic
for many years, and plays an important role in bile duct
decompression and jaundice alleviation (10). Endoscopic
retrograde cholangiopancreatography (ERCP) has also been
widely used in the diagnosis and treatment of HC, especial-
ly combined with endoscopic metal biliary drainage (EMBD)
Zhu J, Feng H, Zhang D, Li R, Li J, Peng H, Tang W, Hu D, Wu W, Hu K, Cai W,
Yin G. Percutaneous transhepatic cholangiography and drainage and endoscopic
retrograde cholangiopancreatography for hilar cholangiocarcinoma: which one is
preferred? Rev Esp Enferm Dig 2020;112(12):893-897
DOI: 10.17235/reed.2020.6937/2020
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© Copyright 2020. SEPD y © ARÁN EDICIONES, S.L.
894
in the treatment of obstructive biliary tract disease (11).
Both PTCD and ERCP are options for the treatment of bili-
ary drainage (12).
In the 1990s, self-expanding metal stents (SEMS) were
applied in the clinic. Several randomized studies have
shown their superiority over plastic stents (13,14). In recent
years, new metal stents and advanced maneuvers have
been developed. For example, multiple self-expandable
metal stent deployment has been studied via side-by-side
and stent-in-stent methods (15), and fully covered self-
expandable metal stents (T-FCSEMS) have been studied
in the clinic (16). It was suggested that the placement of
metal stents is the procedure of choice for the palliation
of malignant biliary obstruction (17-22).
However, little was known about the difference between
PTCD and ERCP to treat hilar cholangiocarcinoma when
combined with SEMS implantation (23). This retrospective
study compared the effects of biliary drainage of SEMS
implantation under PTCD or ERCP to treat unresectable HC.
PATIENTS AND METHODS
Patients
The study was approved by the Ethics Committee of our
hospitals, and the informed consent was waved because it
was a retrospective study. The medical records of patients
newly diagnosed with unresectable HC from January 2006
to January 2015 were recorded. All HC patients had pre-
sented with some clinical symptoms, such as jaundice,
itching, nausea, anorexia, abdominal pain and weight loss.
These were confirmed by computerized tomography (CT),
magnetic resonance imaging (MRI) and other laboratory
tests. The kind of procedure processed was chosen and
decided by the patients themselves. Among all patients, 40
patients had been treated by an ultrasound-guided PTCD
procedure with SEMS implantation, and 42 patients by an
ERCP procedure with SEMS implantation. Four weeks of
follow-up were completed in this retrospective study.
Methods
During PTCD, the biliary system was visualized with a
Chiba needle (Cook, USA) under fluoroscopic guidance. A
5F puncture needle catheter (Cook, USA) was introduced
into the bile duct and the bile duct obstruction was passed
through using a guide wire (Cook, USA). A catheter with
an inner metallic guide wire (micro-tech, Nanjing, China)
was advanced into the duodenum, and then contrast mate-
rial (micro-tech, Nanjing, China) was injected to determine
the overall length of the stenosis. The guide wire was
reinserted and the drainage catheter (micro-tech, Nanjing,
China) was substituted for a self-expanding metallic stent
(SEMS, micro-tech, Nanjing, China) system (Fig. 1A and
B). An 8.5F or 10F external drainage catheter (micro-tech,
Nanjing, China) was inserted percutaneously into an appro-
priate intrahepatic duct simultaneously for three days and
was removed if there were no complications. ERCP was
performed by therapeutic duodenoscopy (TJF-240, Olym-
pus, Japan) and SEMS implantation was used for biliary
drainage (Fig. 1C and D). During the ERCP, stent placement
J. Zhu et al.
A B
C D
Fig. 1. Images of stents implantation under PTCD or ERCP
for the treatment of Bismuth IV hilar cholangiocarcinoma.
A and B. Radiologic images taken under PTCD. C.
Radiologic image taken under ERCP. D. Endoscopic image
under ERCP.
was performed after guide wire placement and directed
contrast injection. One or two stents were placed into the
obstructed biliary tract for all the patients with PTCD and
ERCP, depending on the Bismuth type and the extent of
the obstruction. One stent was placed in Bismuth I-II and
two stents were placed in Bismuth III-IV. Two experienced
endoscopists completed all the PTCD and ERCP procedures
and pre-procedure antibiotics (levofloxacin or cefodizime,
in combination with ornidazole) were given to all the HC
patients. Antibiotics were also routinely used to prevent
infection after ERCP or PTCD. Pancreatic prostheses were
not used during ERCP.
Only patients with a successful PTCD or ERCP were includ-
ed in this retrospective study. Those patients with a failed
ERCP were transferred to undergo PTCD and excluded from
the study. Successful drainage was defined as a normaliza-
tion of serum bilirubin after the procedure or a decrease by
at least half at two weeks after the procedure. Cholangitis
was defined as the presence of abdominal pain and fever
(> 38 °C) within 24 hours after the procedure, without any
other infectious diseases outside of the hepatobiliary sys-
tem that required antibiotics treatment. Pancreatitis was
diagnosed when serum amylase levels were more than
three times above the upper normal limit (60 U/l) with
post-procedural classic persistent epigastric pain, with or
without CT or MRI confirmation. Significant bleeding was
defined as a requirement for a blood transfusion of more
than two units or hemostatic management (including sur-
gery) after the procedure. Procedure-related mortality was
defined as death directly related to the complications of
PTCD or ERCP.
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 Percutaneous transhepatic cholangiography and drainage and endoscopic retrograde cholangiopancreatography for hilar cholangiocarcinoma:
which one is preferred? 895

The general situations of all the patients were carefully
recorded before and after the procedure, including total
bilirubin levels, calculated jaundice improvement rate
(preoperative total bilirubin - postoperative total bilirubin)/
preoperative total bilirubin × 100 %), incidence of complica-
tions and survival time, etc.
hypertension, diabetes mellitus, cardiovascular disease and
weight loss (p > 0.05). There was no statistical significance
of Bismuth type of the HC patients between the ERCP and
PTCD group (p > 0.05).
Effects and complications after bile drainage

Statistical analysis Biliary drainage of each HC patient by an ERCP or PTCD

Statistical analysis was performed with SPSS version
12.0 for Windows (Chicago, USA). Numerical data were
expressed as means ± SD and categorical variables as a
number (ratio). Numerical data were analyzed by the Stu-
dent’s t-test and categorical variables were evaluated using
Pearson’s Chi-squared test and Fisher’s exact test. p < 0.05
was considered as statistically significant.
procedure was successful. Serum total bilirubin (TB)
levels of the HC patients in the PTCD group before and
after the PTCD procedure were 313.1 ± 162.3 mmol/l and
133.7 ± 45.3 mmol/l, respectively. TB levels of the HC
patients in the ERCP group before and after the ERCP pro-
cedure were 283.9 ± 177.7 mmol/l and 133.7 ± 41.8 mmol/l.
There was no significant difference with regard to jaundice
alleviation between these two groups (p > 0.05) (Table 2).

With regard to post-procedural complications, there were

RESULTS
Clinical characteristics before bile drainage
Clinical characteristics of HC patients in the ERCP and
PTCD group are shown in table 1. Among these patients,
40 (70.8 ± 14.3 years, range: 49-86 years) had been treated
by ultrasound-guided PTCD procedure with SEMS implan-
tation, including 22 males. Forty-two patients (68.1 ± 15.4
years, range: 46-89 years), including 24 males, had been
treated by an ERCP procedure with SEMS implantation.
There was no statistical significance with regard to sex, age,
no perforations and obvious bleeding in either group. How-
ever, there were 22 cases (52.4 %) of biliary infection in the
ERCP group and more than eight cases (20.0 %) in the PTCD
group (p < 0.05) (Table 2). In the sub-groups of Bismuth III/IV
HC patients, the biliary infection rate in the ERCP group was
14 cases (58.3 %) and only four cases (14.3 %) in the PTCD
group (p < 0.05) (Table 3). There was no statistical signifi-
cance with regard to complications of pancreatitis between
the two groups (p > 0.05) (Table 2). The median survival
time of the PTCD and ERCP group were 252.2 ± 21.5 days
and 237.3 ± 32.4 days, respectively, with no statistical sig-
nificance (p > 0.05) (Table 2).

Table 1. Clinical characteristics before bile drainage

Clinical characteristics PTCD (n = 40) ERCP (n = 42) p-value
Sex (male/female) 22 (55.0 %) 24 (57.1 %) 0.845
Age (years, range) 70.8 ± 14.3 (49-86) 68.1 ± 15.7 (46-89) 0.381
Hypertension 14 (35.0 %) 17 (40.5 %) 0.609
Diabetes mellitus 6 (15.0 %) 8 (19.0 %) 0.626
Cardiovascular diseases 3 (7.5 %) 4 (9.5 %) 0.743
Weight loss 27 (67.5 %) 25 (59.5 %) 0.454
Bismuth sub-groups
I/II 12 (30.0 %) 18 (42.9 %) 0.227
III/IV 28 (70.0 %) 24 (57.1 %)
PTCD: percutaneous transhepatic cholangiography and drainage; ERCP: endoscopic retrograde cholangiopancreatography.

Table 2. Effects and complications after bile drainage

Groups PTCD (n = 40) ERCP (n = 42) p-value
TB before procedure (mmol/l) 313.1 ± 162.3 283.9 ± 177.7 0.445
TB after procedure (mmol/l) 133.7 ± 45.3 133.7 ± 41.8 0.669
Jaundice alleviation 0.573 ± 0.187 0.529 ± 0.179 0.733
Pancreatitis 0 4 (9.5 %) 0.116
Biliary infection 8 (20.0) 22 (52.4 %) 0.002
Survival time (day) 252.2 ± 21.5 237.3 ± 32.4 0.637
PTCD: percutaneous transhepatic cholangiography and drainage; ERCP: endoscopic retrograde cholangiopancreatography; TB: total bilirubin. Jaundice alleviation = (preoperative TB - postoperative TB
two weeks after procedure) / preoperative TB.

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896
Table 3. Biliary infection rate in the sub-group Bismuth
III/IV between PTCD and ERCP groups
Groups PTCD (n = 40) ERCP (n = 42)
Bismuth I/II 4 (25.0 %) 8 (44.4 %)
Bismuth III/IV 4 (14.3 %) 14 (58.3 %)
PTCD: percutaneous transhepatic cholangiography and drainage; ERCP: endoscopic retrograde
cholangiopancreatography
DISCUSSION
A reasonable choice of palliative treatment is very impor-
tant for unresectable hilar cholangiocarcinoma (HC) cases
with obstructive jaundice. SEMS placement under ERCP
or PTCD is commonly used in the clinic, but which one is
preferred is not yet known (24,25).
Some previous studies have suggested that the biliary
drainage performed by PTCD could only improve the gen-
eral situation of HC patients in a short time and not prolong
survival time due to a large volume of daily bile drainage,
which might cause water electrolyte disorder, malabsorp-
tional malnutrition and biliary infections (7). However, with
the development of interventional techniques and new
instruments, SEMS placement under PTCD without exter-
nal drainage can quickly relieve biliary obstruction, alleviate
jaundice, protect liver function and improve the general
conditions of HC patients (26). In fact, it has been found in
recent years that radiation-emitting metallic stents (REMS)
might be a better choice because it was safer and more
effective for unresectable Bismuth type III or IV hilar cholan-
giocarcinoma. Furthermore, it seemed to prolong survival
as well as the patency of the stent in HC patients (27).
SEMS is supposed to be better for unresectable HC patients
compared to plastic stents. In a study of 134 patients with
malignant choledochal stenosis treated with SEMS place-
ment (128 transpapillary endoscopically and six transhe-
patic percutaneously), the median patency of SEMS was
significantly longer than that of conventional plastic pros-
theses compared with 97 patients with conventional plastic
stents during the same period (28). In our studies, the total
bilirubin levels of 20 HC patients in the PTCD group with
SEMS implantation declined dramatically and the median
survival time increased to 252 days.
It is suggested that a percutaneous approach is more inva-
sive with a higher risk of complications than endoscopic
interventions, which should be considered as the first-line
drainage procedure in most cases of HC patients (24,29).
ERCP might be associated with more immediate procedure-
related complications, although it was certainly not infe-
rior to PTBD in the long term (30). Furthermore, SEMS are
preferable to plastic stents when ERCP is accomplished,
in terms of stent patency, reintervention rates and cost-
efficiency (31-33). When compared to palliative resection,
there was no statistical significance related to jaundice alle-
viation and survival prolongation after an ERCP procedure,
including endoscopic retrograde biliary drainage (ERBD)
or endoscopic metal biliary drainage (EMBD) (34). In our
research, the total bilirubin levels of the 42 HC patients
declined dramatically in the ERCP group and the median
J. Zhu et al.
survival was up to 237 days, with no statistical significance
compared to the PTCD group (p > 0.05).
p-value In this retrospective study, there was a higher biliary infec-
0.709 tion rate in the ERCP group compared to the PTCD group
(p < 0.05), which was consistent with the findings of Paik (35).
0.002 However, there was no statistical significance with regard to
drainage effect and patients’ survival time (p > 0.05). This
might be due to a high intraductal pressure caused by endo-
scopic retrograde cholangiopancreatographic injection of
contrast and concomitant duodenal fluid reflux during the
ERCP procedure. During ERCP, endoscopic accessories must
be inserted through the duodenal natural orifice into the
common bile duct, which will take duodenal bacteria into
the biliary system. ERCP is an invasive procedure, which
inevitably results in minimal mucosal injury. Moreover, HC
patients who need endoscopic treatment are always Bis-
muth type III or IV. In these patients, super selection of two
guide wires into the left and the right hepatic duct separately
through the narrow section of tumor is very difficult to com-
plete, leading to a longer operation time. Furthermore, the
catheterization of the left hepatic duct and right hepatic duct
can sometimes block the proximal bile duct, causing con-
trast and bile reflux and insufficient bile drainage to some
extent. All these factors are high risk factors of ERCP-related
biliary infection in HC patients.
The incidence of biliary infection was 52.4 % after the ERCP
procedure in our study, which might be due to more Bis-
muth type III or type IV patients. With regard to Bismuth
type III or type IV patients, the incidence of biliary infec-
tion was 58.3 % in the ERCP group, which was significantly
higher than 14.3 % in PTCD group, which was statistically
significant (p < 0.05). The biliary infection rate in the PTCD
group was lower than in the ERCP group. One possible
explanation is that the PTCD procedure was relatively asep-
tic, which reduced the probability of bacteria being taken
into the biliary tract compared to ERCP. In addition, the
PTCD catheter was routinely retained after the SEMS was
implanted in the common bile duct, which could increase
the external bile drainage, accelerate the discharge of con-
trast and decrease the incidence of biliary infection.
It is curious that the rates of infection in the PTCD group in
HC patients with Bismuth I-II were higher than in Bismuth
III-IV (25 % vs 14 %). One possible reason is that there were
much more contrast agents during the PTCD procedure.
One external drainage in Bismuth I-II patients was not good
enough to drain the injected contrast, while two external
drainages in Bismuth III-IV patients made it a little bit better.
Bias caused by the few HC patients included is also a pos-
sibility. Further studies are needed to clarify this problem.
In conclusion, both PTCD and ERCP procedures with intra-
ductal SEMS implantation in HC patients could achieve
the same biliary drainage effect and prolong the survival
time in HC patients. However, PTCD had a lower rate of
biliary tract infection, especially for Bismuth type III or IV
HC patients. Therefore, from this point of view, PTCD might
be more appropriate for Bismuth type III or IV HC patients.
This study also has some limitations, such as the different
levels and tumor burdens, as more Bismuth type IV tumor
patients were included. In addition, part of the data of bili-
ary drainage was missing and there were different ways of
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 Percutaneous transhepatic cholangiography and drainage and endoscopic retrograde cholangiopancreatography for hilar cholangiocarcinoma:
which one is preferred?
dealing with adverse events. These may lead to a deviation
in the results of the study.
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