Use of a cholangioscopy-guided retrieval snare for the macrobiopsy of a choledochal polyp

A 65-year-old man with a 1-year history of recurrent episodes of right upper quadrant colicky pain presented with this complaint to our outpatient clinic. The patient’s past medical history included hypertension. He underwent a transabdominal ultrasound scan, which showed a hypoechoic nodular lesion of 12 mm in the proximal common bile duct (CBD), without evidence of distension of the intrahepatic biliary ducts. Therefore, an endoscopic ultrasound (EUS) was scheduled and performed. The EUS examination confirmed the presence of a hypoechoic nodular lesion of 13 × 12 mm in the proximal CBD, along with a slight biliary stricture. Given the suspicion of cholangiocarcinoma, endoscopic retrograde cholangiopancreatography (ERCP) was indicated. After informed consent for the procedure and appropriate sedation had been given, ERCP was performed.

Cholangiography showed a slight biliary stricture in the proximal CBD. After sphincterotomy had been performed, we proceeded to peroral intraductal cholangioscopy (IDC) using the Spyglass DS system. IDC showed a polypoid lesion, with a papillary pattern and an irregular undilated vessel (F3-V2) [1], of almost 13 mm in the proximal CBD without hilar involvement ([Fig. 1 a]). A cholangioscopy-guided cold macrobiopsy of the choledochal polyp was successfully performed using an IDC snare (Spyglass retrieval snare) and the specimen was collected for histopathological examination ([Fig. 1 b]; [Video 1]). At the end of the procedure, the resection site was clear and there was no evidence of either bleeding or biliary leakage.

Fig. 1 Cholangioscopic images showing: a a polypoid lesion in the common bile duct; b cold macrobiopsy being performed with an intraductal retrieval snare.

Video 1 Use of a cholangioscopy-guided retrieval snare for the macrobiopsy of a choledochal polyp.

Histopathological examination showed polypoid fragments with villous architecture and high grade dysplasia, with focal areas of intramucosal adenocarcinoma ([Fig. 2]). The patient was therefore referred for surgical evaluation.

Fig. 2 Histopathological appearance showing polypoid fragments with villous architecture and high grade dysplasia, with focal areas of intramucosal adenocarcinoma.

We, herein, describe a patient with a choledochal polyp who underwent IDC followed by macrobiopsy using an IDC retrieval snare. Although the use of an IDC-guided retrieval snare has been previously described for the removal of biliary stones and retained prostheses [2], its use for macrobiopsy of a choledochal polyp has not been previously reported. This case demonstrates the effective use of an IDC retrieval snare as a valid alternative for the sampling of choledochal lesions to achieve a valid histological diagnosis.

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Publikationsverlauf

Artikel online veröffentlicht:
15. Februar 2022

• References

• 1 Fukasawa Y, Takano S, Fukasawa M. et al. Form-Vessel classification of cholangioscopy findings to diagnose biliary tract carcinomaʼs superficial spread. Int J Mol Sci 2020; 21: 3311
• 2 Fejleh MP, Thaker AM, Kim S. et al. Cholangioscopy-guided retrieval basket and snare for the removal of biliary stones and retained prostheses. VideoGIE 2019; 4: 232-234