Endoscopic or percutaneous biliary drainage in hilar cholangiocarcinoma:When and how?

Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dimprognosis. The role of preoperative and palliative biliary drainage has long beendebated. The most common techniques are endoscopic retrograde cholangiopancreatography(ERCP) and percutaneous transhepatic biliary drainage (PTBD);however, recently developed endoscopic ultrasound-assisted methods are gainingmore atention. Selecting the best available method in any specific scenario iscrucial, yet sometimes challenging. Thus, this review aimed to discuss theavailable techniques, indications, perks, pitfalls, and timing-related issues in themanagement of hCCA. In a preoperative setting, PTBD appears to have someadvantages: low risk of postprocedural complications (namely cholangitis) andbetter priming for surgery. For palliative purposes, we propose ERCP/PTBDdepending on the experience of the operators, but also on other factors: the levelof bilirubin (if very high, rather PTBD), length of the stenosis and the presence ofcholangitis (PTBD), ERCP failure, or altered biliary anatomy.