Primary sclerosing cholangitis (PSC) is characterized by focal intrahepatic and extrahepatic
bile duct stricture, and often causes jaundice due to dominant biliary strictures
during its course [1]. The biliary stricture is usually dilated via mechanical dilation under endoscopic
retrograde cholangiopancreatography (ERCP) guidance; however, PSC-related biliary
strictures are sometimes too stenotic due to rich fibrosis to allow the passage of
conventional dilation devices. Recently, a novel drill dilator (Tornus ES, Asahi Intecc,
Aichi, Japan) has been developed and made commercially available which is design to
traverse difficult pancreaticobiliary strictures [2]
[3]
[4]. The spiral-threaded part of the dilator allows it to pass through the stricture
on clockwise rotation ([Fig. 1]). The tip of the dilator is finely tapered to allow insertion of a guidewire with
a diameter ≤ 0.025 inch. Here, we report successful use of the novel drill dilator
for challenging severe biliary stricture when other conventional accessories would
not work.
Fig. 1 Magnification of the tip of a novel drill dilator (Tornus ES, Asahi Intecc, Aichi,
Japan). The drill dilator consists of spiral threads around the shaft. The outer diameter
of
the dilator is 7F. The tip of the dilator is finely tapered to allow insertion of
a
guidewire with a diameter ≤0.025 inch.
A 27-year-old male patient with a 6-year history of PSC was referred to our hospital
with jaundice. Magnetic resonance cholangiopancreatography revealed a dominant biliary
stricture at the hepatic hilum ([Fig. 2]). ERCP was performed to manage the hilar biliary stricture. A 0.025-inch guidewire
was successfully passed through the stricture, although dilated intrahepatic bile
ducts could not be imaged on the cholangiogram. Subsequently, mechanical dilation
was attempted; however, neither the cannulation catheter, bougie dilator (ES dilator,
Zeon Medical, Tokyo, Japan) ([Fig. 3]) [5], nor the Soehendra stent retriever (Cook Medical, Winston-Salem, North Carolina,
United States) was able to advance past the stricture. Therefore, a novel drill dilator
was used. The drill dilator passed smoothly through the hard biliary stricture without
strong pressure on the device by clockwise rotation ([Fig. 4], [Video 1]). The biliary stricture was further dilated using a 4-mm balloon dilator. The patient’s
jaundice resolved in a few weeks after ERCP, without any adverse events.
Fig. 2 Magnetic resonance cholangiopancreatography showing a dominant biliary stricture at
the hepatic hilum (arrowhead)
Fig. 3 Although a 0.025-inch guidewire was successfully passed through the stricture at the
hepatic hilum, a tip-tapered bougie dilator (ES dilator, Zeon Medical, Tokyo Japan)
could not advance the stricture. a Endoscopic image. b Fluoroscopic image.
Fig. 4 Clockwise rotation allows the drill dilator to pass smoothly through the severe biliary
stricture. a Endoscopic image. b Fluoroscopic image.
Successful dilation of a hard hilar biliary stricture using a novel drill dilator.Video
1
