PTCS-guided holmium laser incision is a promising new adjuvant treatment for benign biliary strictures. Real-time monitoring under direct endoscopic visualization provides an invaluable opportunity for Interventional Radiologists to safely perform targeted diagnosis and treatment within the biliary system. Despite limited literature on the subject, there are several potential advantages of bringing cholangioscopic laser incision to the Interventional Radiology (IR) suite.

First, management of biliary strictures and their sequelae is commonplace in daily IR practice. With increasing sophistication of modern therapeutics including ablation, lithotripter, stent and retrieval devices, there is increasing risk to using fluoroscopy alone to perform complex interventions in a three-dimensional space. Endoscopy allows real-time monitoring of treatment progress and potential complications. For example, an operator using fluoroscopy could not identify iatrogenic haemobilia as readily as an operator using endoscopy, and delayed recognition of such a complication could have lethal consequences. Fortunately, hemorrhagic complications encountered in the IR suite can be treated by trans-arterial embolization. Endoscopic visualization also allows an operator to more precisely characterize the etiology, extent, and other specific features of a focal narrowing within the bile ducts, thus facilitating a more targeted and patient-specific approach to diagnosis and treatment. Conversely, a filling defect seen on conventional cholangiography is nonspecific and can result in an indeterminant biopsy or lead to inappropriate treatment.

Second, PTCS-guided laser incision can improve clinical outcomes and potentially be a definitive treatment option for patients with recalcitrant BBS who otherwise require life-long percutaneous drainage. Unlike mechanical dilation techniques such as balloon cholangioplasty and stenting, the holmium laser addresses the root cause of stricture by incising excess fibrotic intraluminal tissue and restoring patency to the native bile duct, while also eliminating the need for an indwelling device that can become a nidus for infection. In contrast to radiofrequency (RF) ablation or the neodymium laser, the holmium laser's short depth of penetration and selective wavelength for water absorption results in precise tissue dissection by way of vaporization, with minimal thermal damage to surrounding tissues. This results in less inflammation and trauma to the bile ducts, which are the major culprits of re-stenosis. Additionally, the device can be employed simultaneously for lithotripsy of concomitant biliary stones which must be removed at the time of intervention to prevent cholangitis and stricture recurrence.

Third, PTCS-guided laser incision has the potential to reduce patient morbidity and improve quality of life. By decreasing the total number of interventions and amount of time patients require a drainage catheter or other indwelling device, a decrease in cumulative procedural and stricture-related complications would likewise be expected. In contrast to 1 or 2 PTCS sessions, standard protocols involve multiple interventions over the course of several months, during which time patients are expected to self-manage a biliary drainage bag and continuously monitor for signs and symptoms of cholangitis and elevated bilirubin. Following a capping trial, still some 20-30% of patients develop recurrent stricture, many of whom have no other option but to continue indefinitely with a drainage tube while carrying a life-long risk of recurrent cholangitis and other obstructive phenomena. The improved efficiency of PTCS-guided laser incision also implicates a potential to decrease procedure-related costs, use of hospital and departmental resources, and radiation exposure to patients. In the past, the high overhead cost of reusable endoscopes prohibited most IR groups from adopting endoscopy. However, the development of new disposable low-profile devices has eliminated the financial barrier to entry for IR-operated endoscopy and may yield cost savings over time with less angiography suite usage.