Commentary

Patients with surgically resected pancreatic or gastric adenocarcinoma presenting with biliary strictures raise concerns about recurrent malignancy. Cholangioscopy is the most accurate diagnostic approach. However, surgically altered anatomy hampers retrograde biliary access in these patients. Percutaneous transhepatic cholangioscopy is possible, but inconvenient and rarely performed for diagnosis. In this report, Rosa et al. were able to exclude malignancy in a Roux-en-Y gastrectomy patient by using peroral transhepatic cholangioscopy with biopsies via an endoscopic ultrasound (EUS)-guided hepaticojejunostomy. After tract maturation, a disposable baby-cholangioscope was passed antegradely into the bile duct.

Transmural EUS-guided placement of lumen-apposing or regular stents creates true anastomoses. Different endoscopes can be passed either through the stent or through mature fistulas. Pancreatic necrosectomy, cholecystoscopy with gallstone removal, or transgastric ERCP from pouch to remnant stomach in Roux-en-Y gastric bypass, can thus be performed. Peroral transluminal cholangioscopy applies this same principle. Although originally reported in malignant disease [1], it is increasingly being used in complex benign biliary obstruction [2] [3] [4]. Covered metal stents allow single-session through-the-stent direct cholangioscopy [5]. In the present case, a plastic stent was used, making tract maturation and use of a thinner baby-cholangioscope necessary. Regardless of technique variations, peroral transluminal cholangioscopy is a nascent spin-off of EUS-guided biliary drainage. This E-Video illustrates its potential to improve pancreatobiliary disease management.

Publication History

Article published online:
25 November 2020

• References

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