Photodynamic Therapy of Biliary Tract Tumors under Direct Visualization via Percutaneous Transhepatic towards the Hilar Bile Duct

Conventional photodynamic therapy via the percutaneous transhepatic cholangial (PTC) route typically requires puncture of peripheral bile ducts, often involving third-order or higher biliary branches, and is performed after delayed sinus tract dilation. This approach is often limited by rib interference during the puncture process, and the insertion of rigid cholangioscopes is significantly restricted by the angulation of the bile ducts. These factors substantially limit exploration and treatment of the hilar region and common bile duct (CBD). Based on our previous experience, our team has developed a technique that utilizes ultrasound-guided puncture of first-second order bile ducts with one-stage dilation of the sinus tract, allowing direct access to the hilar and CBD regions. This enables direct-vision biopsy of hilar masses, balloon dilation of hilar strictures, biliary stent placement, and photodynamic therapy. This approach has advantages such as a shorter access route, improved operative angles and visualization, and a broader range of exploration. In our previous studies, more than 500 cases underwent puncture of first-second order bile ducts with one-stage dilation for the treatment of hepatolithiasis and benign or malignant biliary strictures. There were no perioperative deaths and no complications of Clavien-Dindo grade III or higher, demonstrating the high safety and technical simplicity of the procedure. This approach provides an effective option for local treatment of locally advanced and late-stage biliary tract tumors.