PERCUTANEOUS TRANSHEPATIC CHOLANGIOSCOPY (PTC) USING THE SPYGLASS SPYSCOPE SYSTEM FOR STRICTURES OF THE COMMON BILE DUCT

Aims Bile duct strictures are challenging conditions that require a multidisciplinary approach involving gastroenterologists and radiologists. Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic tool for the evaluation of these strictures but is challenging in cases of gastrectomy and Roux-en-Y reconstruction. When conventional ERCP fails, common bile duct (CBD) strictures could be managed with percutaneous transhepatic cholangiography (PTC). The combination of PTC and cholangioscopy using the Spyglass system (Boston Scientific Inc., Massachusetts, USA) could provide a better tool to establish diagnosis and treatment.

Methods Three patients were referred to our department after a failed ERCP due to subtotal gastrectomy and Roux-en-Y reconstruction for evaluation of common bile duct strictures. CBD stenosis was revealed during PTC for treatment of recurrent cholangitis due to localized strictures. In collaboration with our interventional radiology department, we performed percutaneous transhepatic cholangioscopy using the Spyglass system to visualize the stricture, obtain tissue specimens, establish diagnosis and apply treatment.The Spyglass system was inserted, via percutaneous transhepatic way, then progressed throughout the biliary tree to the more proximal branches and finally to the common bile duct.

Results The mean age of the patients was 78 years old. Both technical and clinical success was 100% (3/3). Cholangioscopy revealed localized lesions of CBD with villous appearance without neovascularization. Histopathological analysis revealed a localized inflammatory reaction, a presence of an hyperplastic polyp and a fibrotic stricture, without evidence of malignancy in all patients. A fully covered metal stent (8 mm x 60 mm) was successfully applied to one of the patients.

Conclusions Percutaneous transhepatic cholangiography can resolve diagnostic dilemmas when conventional access to the biliary tree is impossible, as for example in cases of subtotal gastrectomy and Roux-en-Y reconstruction. The addition of Spyglass system improves the diagnostic accuracy and provides additional clinical benefit to histopathological assessment for the diagnosis and treatment of biliary strictures.