PERFORATION OF THE COMMON BILE DUCT DURING SPYGLASS CHOLANGIOSCOPY IN A PATIENT WITH IGG4-RELATED SCLEROSING CHOLANGITIS (IGG4-SC)

Aims SpyGlass cholangioscopy is increasingly performed for the evaluation of indeterminate biliary lesions. Although it has demonstrated favorable safety, additional complications are expected to arise with expanded use of this technology. We describe an uncommon case of common bile duct (CBD) perforation associated with cholangioscopy.

Methods An 72 year-old man with diabetes mellitus was referred for ERCP due to a 1-month history of obstructive jaundice. MRCP revealed perihilar and distal bile duct stenosis, with normal main pancreatic duct. The CA-19.9 levels were normal, but the IgG4 serum levels were elevated (496 mg/dL). An ERCP with cholangioscopy was performed for further evaluation.

Results Cholangioscopy confirmed both perihilar and CBD strictures demonstrating irregular mucosa, increased vascularity, and papillary-appearing mucosal projections. Tissue sampling of the perihilar stricture was challenging due to excessive resistance encountered during advancement of the SpyBite catheter. The cholangioscope was then withdrawn at the distal CBD and an attempt was made to re-advance the cholangioscope by way of a free hand technique with the closed SpyBite forceps marginally protruding through its tip. This has led to a visible mechanical perforation of the distal CBD, confirmed by the presence of retroperitoneal emphysema on abdominal CT. A 10 Fr plastic biliary stent was inserted followed by conservative measures, including antibiotics and withholding oral intake. The patient was discharged 10 days after perforation following an uneventful recovery. The diagnosis of IgG4-SC was most probable and steroid treatment was initiated. A follow-up ERCP performed 3 months after the institution of steroids revealed stricture disappearance and the stent was removed.

Conclusions Perforation of the CBD wall may occur during SpyGlass cholangioscopy, although it is uncommon and can be treated conservatively. Free-hand technique and protrusion of the SpyBite forceps out of the working channel as well as the underlying IgG4-SC pathology might be risk factors.