Current interventional options for palliative care for patients with advanced-stage cholangiocarcinoma

Table 1 Palliative treatment options for cholangiocarcinoma and their associated techniques, indications, and complications

Type	Technique	Indication	Complications
Percutaneous drainage	PTBD	Proximal malignant biliary obstructions (particularly Bismuth type III and IV peri-hilar CCA patients)	Catheter-related complications: wound care, hygiene maintenance, catheter dislodgement, and PTBD blockages
			Acute cholangitis, bleeding, and peri catheter leakage
	PTBS	Specific patients with malignant biliary obstruction	No catheter-related complications (due to no external drainage)
			Cholangitis, pancreatitis, bleeding, stent dysfunction, cholecystitis, duodenal perforation, stent obstruction (due to tumor overgrowth)
Endoscopic drainage	ERCP with biliary stenting	Patients with incurable conditions (e.g. Unresectable tumors, malignant hilar obstruction)	Stent occlusion or dysfunction (mainly due to tumor ingrowth)
	EUS-EBD	Cases where ERCP may be difficult due to anatomical variations, altered anatomy from prior surgeries or tumor infiltration	Minimal complications including pancreatitis and cholecystitis
Surgical Drainage (only considered as a final option after failure of other approaches)	Choledochojejunostomy	Distal CCA	High perioperative morbidity and mortality
	Intrahepatic bile duct bypass	Peri hilar CCA
	Extrahepatic bile duct bypass	Distal obstruction or Bismuth type I
	Left hepaticojejunostomy	Bismuth type IIIa
	Right hepaticojejunostomy	Bismuth type IIIb
	Right or left sectoral duct bypass	Bismuth type IV	High perioperative morbidity and mortality
			Frequently ineffective due to inadequacy of a single anastomosis to drain a sufficient volume of functioning liver

PTBD: Percutaneous transhepatic biliary drainage; PTBS: Percutaneous transhepatic biliary stenting; ERCP: Endoscopic retrograde cholangiopancreatography; EUS-EBD: Endoscopic ultrasound guided endoscopic biliary drainage; CCA: Cholangiocarcinoma.