Direct visualization of the biliary tree is achieved by means of endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography that provide a precise and complete opacification with contrast material.
Since the introduction of ultrasound (CT and especially MRCP) in clinical practice, indication of these techniques for diagnosis has decreased and they are mainly applied for operative purposes. The application of these direct and invasive techniques has to be proposed by the hepatobiliary team since the choice of method, either ERCP or PTC, is fundamental. If the latter is chosen, it is necessary to specify the right or left approach; in fact the choice of the exact method must be tailored to the needs of the patient, considering the diagnostic purpose as well as the therapeutic possibility (surgical resection, surgical palliation, non-surgical palliation).
The techniques show noticeable complication rates; PTC has a morbidity rate of 3-5% and the main complications are cholangitis, biliary leakage with potential bile peritonitis or perihepatic biliary collection (biloma), haemobilia, bil-hemia, and subcapsular or intrahepatic haematoma. The complications of ERCP
are cholangitis whose risk is enhanced by severe stenosis, since the introduction of the contrast that is not drained increases infective risk; to prevent infection, biliary decompression after the diagnostic procedure of the stenosis is mandatory.
Success rates of PTC range from 95 to 100% of jaundiced patients with biliary obstruction, while for ERCP with a recognized papilla, the rate is about 90%.
Of the two procedures PTC allows a better evaluation of cholangiocarcinoma, especially hilar compared to ERCP since it can better visualize the proximal biliary tract above the stenosis. The advantage of ERCP compared to PTC and MRCP is the possibility of performing brushing cytology or intraductal biopsy for pathological evaluation; however the success rate of these technique is low, about 50-60% .
On direct cholangiography, cholangiocarcinoma shows as an annular stricture since most of the tumour is infiltrative. Polypoid type is rare and some forms producing mucin present intraluminal defects.
PTC performed by experienced personnel  and in large series correctly shows the site of stenosis in a range between 96 and 99% and reveals the nature of the lesion at a rate of between 93 to 99%, respectively.
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