Endoscopic removal of tubulovillous adenoma with high grade focal dysplasia in the distal common bile duct

An 80-year-old woman with pluripathology was admitted with cholangitis. A computed tomography scan showed a dilated common bile duct (CBD) and a possible distal choledocholithiasis. An endoscopic retrograde cholangiopancreatography was performed and the duct was swept with a balloon, revealing a polypoid lesion of adenomatous appearance through the papilla. The pathology confirmed a tubulo-villous adenoma with high grade focal dysplasia. An endoscopic ultrasound revealed the presence of a 10 × 8 mm polyp in the CBD ([Fig. 1]). As the patient was a high risk surgical candidate, endoscopic treatment was indicated in accordance with a multidisciplinary committee.

Fig. 1 Initial imaging. a Endoscopic retrograde cholangiopancreatography showed a filling defect at the distal common bile duct. b An endoscopic ultrasound revealed the presence of a 10 × 8 mm polyp.

The papilla was reached using the duodenoscope and a papilloplasty was performed with a 12-mm pneumatic balloon ([Video 1]). With the help of the Fogarty balloon and a biopsy forceps, the polyp was tractioned toward the duodenum and polypectomy was performed using a pediatric hot snare ([Fig. 2]). Then, a fulguration soft coagulation was done and a fully covered self-expanding metallic biliary stent was placed.

Video 1 Endoscopic removal of a tubulovillous adenoma with high grade focal dysplasia in the distal common bile duct.

Fig. 2 Removal of the polyp. a Using a Fogarty balloon, the polyp was tractioned toward the duodenum. b Polypectomy was performed using a pediatric hot snare.

After a 2-month follow-up period, a baby scope cholangioscopy showed no macroscopic lesion after removing the stent. In addition, fulguration with argon beam was applied to the polypectomy site. In the next follow-up at 6 months, a baby scope cholangioscopy showed no remaining polyp ([Fig. 3]). Pathology confirmed the absence of adenoma at 2 and 6 months. No complications were detected during follow-up.

Fig. 3 No remaining polyp was seen with a baby scope cholangioscopy at the 6-month follow-up visit. Pathology confirmed the absence of adenoma at 2 and 6 months.

Adenomas of the extrahepatic bile duct are uncommon benign neoplasms with an unknown malignant potential [1] [2] [3]. Surgery is the current treatment [1] [2] [3], with only five published cases of successful endoscopic treatment in nonsurgical patients [2]. In the current case, the key to achieving technical success was good visualization through the papilla (papilloplasty + stent) and the use of a pediatric polypectomy snare with the help of the balloon.

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• References

• 1 Burhaus R, Myers RT. Benign neoplasms of the extrahepatic biliary ducts. Am Surg 1971; 37: 161-166
• 2 Loh K, Nautsch D, Mueller J. et al. Adenomas involving the extrahepatic biliary tree are rare but have an aggressive clinical course. Endosc Int Open 2016; 4: E112-E117
• 3 Munshi AG, Hassan MA. Common bile duct adenoma: case report and brief review of literature. Surg Laparosc Endosc Percutan Tech 2010; 20: e193-e194