Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Percutaneous transhepatic cholangioscopy

Hiroto Kita, MD, PhD
Section Editor
Douglas A Howell, MD, FASGE, FACG
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF


Miniature intraductal endoscopes have an increasingly 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) [1,2]. Percutaneous transhepatic cholangiography and peroral cholangioscopy and pancreatoscopy are discussed separately. (See "Percutaneous transhepatic cholangiography" and "Cholangioscopy and pancreatoscopy".)


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 invasive 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) [3,4].

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


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Sep 22, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Takada T, Suzuki S, Nakamura K, et al. Studies in percutaneous biliary tract endoscopy. Gastroenterol Endosc 1974; 16:106.
  2. Nimura Y, Hayakawa N, Toyoda S, et al. Percutaneous transhepatic cholangioscopy. Stomach Intestine 1981; 16:681.
  3. Ross AS, Kozarek RA. Cholangioscopy: where are we now? Curr Opin Gastroenterol 2009; 25:245.
  4. Jung JY, Lee SK, Oh HC, et al. The role of percutaneous transhepatic cholangioscopy in patients with hilar strictures. Gut Liver 2007; 1:56.
  5. Itoi T, Sofuni A, Itokawa F, et al. Peroral cholangioscopic diagnosis of biliary-tract diseases by using narrow-band imaging (with videos). Gastrointest Endosc 2007; 66:730.
  6. Itoi T, Ishii K, Tsuji S, et al. Diagnostic videocholangioscopy using narrow-band imaging and recanalization by rendezvous technique for difficult benign biliary stricture. Dig Endosc 2009; 21 Suppl 1:S108.
  7. Martin WR, Riemann JF. Perkutane transhepatische Cholangioskopie. In: Gastroenterologische Endoskopie, Fruehmorgen P, Springer, Berlin, Heidelberg (Eds), New York 1999. p.151.
  8. Yoshimoto H, Ikeda S, Tanaka M, Matsumoto S. Relationship of biliary pressure to cholangiovenous reflux during endoscopic retrograde balloon catheter cholangiography. Dig Dis Sci 1989; 34:16.
  9. Sato M, Inoue H, Ogawa S, et al. Differences in fine mucosal structure between superficial spreading carcinoma and non-neoplastic bile duct mucosa detected by percutaneous transhepatic cholangioscopy. Dig Endosc 1997; 9:43.
  10. Nimura Y. Staging of biliary carcinoma: cholangiography and cholangioscopy. Endoscopy 1993; 25:76.
  11. Tamada K, Kurihara K, Tomiyama T, et al. How many biopsies should be performed during percutaneous transhepatic cholangioscopy to diagnose biliary tract cancer? Gastrointest Endosc 1999; 50:653.
  12. Nimura Y, Kamiya J. Cholangioscopy. Endoscopy 1998; 30:182.
  13. Tamada K, Ueno N, Tomiyama T, et al. Characterization of biliary strictures using intraductal ultrasonography: comparison with percutaneous cholangioscopic biopsy. Gastrointest Endosc 1998; 47:341.
  14. Neuhaus H, Hoffmann W, Classen M. [The benefits and risks of percutaneous transhepatic cholangioscopy]. Dtsch Med Wochenschr 1993; 118:574.
  15. Van Steenbergen W, Van Aken L, Van Beckevoort D, et al. Percutaneous transhepatic cholangioscopy for diagnosis and therapy of biliary diseases in older patients. J Am Geriatr Soc 1996; 44:1384.
  16. Seo DW, Kim MH, Lee SK, et al. Usefulness of cholangioscopy in patients with focal stricture of the intrahepatic duct unrelated to intrahepatic stones. Gastrointest Endosc 1999; 49:204.
  17. Sato M, Inoue H, Ogawa S, et al. Limitations of percutaneous transhepatic cholangioscopy for the diagnosis of the intramural extension of bile duct carcinoma. Endoscopy 1998; 30:281.
  18. Lee SS, Kim MH, Lee SK, et al. MR cholangiography versus cholangioscopy for evaluation of longitudinal extension of hilar cholangiocarcinoma. Gastrointest Endosc 2002; 56:25.
  19. Bonnel DH, Liguory CE, Cornud FE, Lefebvre JF. Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients. Radiology 1991; 180:345.
  20. Takada T, Uchiyama K, Yasuda H, Hasegawa H. Indications for the choledochoscopic removal of intrahepatic stones based on the biliary anatomy. Am J Surg 1996; 171:558.
  21. Simon T, Fink AS, Zuckerman AM. Experience with percutaneous transhepatic cholangioscopy (PTCS) in the management of biliary tract disease. Surg Endosc 1999; 13:1199.
  22. Brambs HJ, Duda SH, Rieber A, et al. Treatment of bile duct stones: value of laser lithotripsy delivered via percutaneous endoscopy. Eur Radiol 1996; 6:734.
  23. Harris VJ, Sherman S, Trerotola SO, et al. Complex biliary stones: treatment with a small choledochoscope and laser lithotripsy. Radiology 1996; 199:71.
  24. Yeh YH, Huang MH, Yang JC, et al. Percutaneous trans-hepatic cholangioscopy and lithotripsy in the treatment of intrahepatic stones: a study with 5 year follow-up. Gastrointest Endosc 1995; 42:13.
  25. Lee SK, Seo DW, Myung SJ, et al. Percutaneous transhepatic cholangioscopic treatment for hepatolithiasis: an evaluation of long-term results and risk factors for recurrence. Gastrointest Endosc 2001; 53:318.
  26. Kim JH, Lee SK, Kim MH, et al. Percutaneous transhepatic cholangioscopic treatment of patients with benign bilio-enteric anastomotic strictures. Gastrointest Endosc 2003; 58:733.
  27. Itoi T, Shinohara Y, Takeda K, et al. A novel technique for endoscopic sphincterotomy when using a percutaneous transhepatic cholangioscope in patients with an endoscopically inaccessible papilla. Gastrointest Endosc 2004; 59:708.
  28. Itoi T, Sofuni A, Itokawa F, et al. Salvage therapy in patients with unresectable hilar cholangiocarcinoma. Digestive Endoscopy 2006; 18:232.
  29. Oh HC, Lee SK, Lee TY, et al. Analysis of percutaneous transhepatic cholangioscopy-related complications and the risk factors for those complications. Endoscopy 2007; 39:731.
  30. Maier M, Kohler B, Benz C, et al. [Percutaneous transhepatic cholangioscopy (PTCS)--an important supplement in diagnosis and therapy of biliary tract diseases (indications, technique and results)]. Z Gastroenterol 1995; 33:435.
  31. Chen MF, Jan YY. Bacteremia following postoperative choledochofiberscopy--a prospective study. Hepatogastroenterology 1996; 43:586.
  32. Yamakawa T, Itoh S, Hirosawa K, et al. Seeding of gallbladder carcinoma along the tract after percutaneous transhepatic choledochoscopy. Am J Gastroenterol 1983; 78:649.