Which hepatic duct segments should be drained in unresectable hilar cholangiocarcinoma type 3A?

Drainage Strategy for Unresectable Hilar Cholangiocarcinoma Type 3A

For Bismuth type 3A hilar cholangiocarcinoma, percutaneous transhepatic biliary drainage (PTBD) is preferred over endoscopic drainage, with selective unilateral drainage of the larger hepatic lobe (typically right-sided) being sufficient in most cases. 1

Preferred Drainage Approach

Percutaneous drainage should be the primary modality for type 3A disease based on the following evidence:

• The 2025 EASL guidelines specifically recommend percutaneous drainage for Bismuth type III tumors 1
• Meta-analyses demonstrate that PTBD achieves higher odds of successful biliary drainage (OR 2.53; 95% CI 1.57-4.08) compared to endoscopic drainage in type III and IV disease 1
• PTBD shows a tendency toward lower overall adverse event rates and 30-day mortality in advanced perihilar cholangiocarcinoma 1
• Clinical success rates are higher with PTBD, and there is a lower incidence of cholangitis compared to endoscopic approaches in this patient population 1

Which Segments to Drain

Unilateral drainage targeting the larger hepatic lobe (usually right-sided in type 3A) is the recommended initial approach:

• Selective drainage of the future liver remnant or larger hepatic volume is sufficient for most patients 2
• For type 3A specifically (right hepatic duct involvement), draining the right hepatic system provides adequate decompression 2
• Recent data suggest draining more than 50% of liver volume provides favorable long-term results 3

Bilateral drainage should be considered only in specific circumstances:

• If cholangitis develops after unilateral drainage 2
• In cases of slow-resolving hyperbilirubinemia despite adequate unilateral drainage 2
• When cholangitis is already present at diagnosis, draining all obstructed segments is beneficial 3

Stent Selection

Self-expanding metal stents (SEMS) are strongly preferred over plastic stents:

• The 2025 EASL guidelines recommend uncovered self-expanding metal stents for advanced perihilar cholangiocarcinoma 1
• Meta-analyses show SEMS provide superior outcomes including better drainage success rates, improved survival, fewer re-interventions, and better 6-month patency rates 1
• Metal stents are more cost-effective for patients with life expectancy greater than 6 months 4

Critical Pitfalls to Avoid

Do not attempt to drain all segments indiscriminately:

• Injecting contrast into segments that cannot be adequately drained significantly increases the risk of post-procedure cholangitis 1, 2
• Incomplete drainage of contrast-injected segments is a major cause of infectious complications 3

Avoid routine preoperative drainage in potentially resectable cases:

• Biliary drainage should only be performed in unresectable disease or specific indications (acute cholangitis, need for portal vein embolization) 4, 2
• Unnecessary drainage increases risks of tract seeding and inflammatory reactions 2

Alternative if PTBD Fails or Unavailable

• EUS-guided biliary drainage (EUS-BD) has emerged as a safe alternative when performed by experienced endoscopists in referral centers 1
• EUS-BD shows better clinical success rates and lower adverse events compared to PTBD in some studies, though it requires significant expertise 1
• Repeated ERCP remains a valuable option if initial endoscopic cannulation fails 1

Goals of Drainage

The primary objectives are to:

• Alleviate or prevent cholangitis 1
• Reduce serum bilirubin to levels compatible with chemotherapy administration 1
• Improve quality of life 1