Endoscopic “combined-arms approach” for the management of a giant intraductal papillary mucinous neoplastic lesion of the bile duct

An intraductal papillary mucinous neoplastic lesion (IPMN) of the bile duct is a rare, difficult-to-treat disease causing complex strictures of the biliary tree. For patients who are not amenable to radical surgery, maintaining patent bile ducts requires an individualized approach, with endoscopists sometimes resorting to outside-the-box solutions to provide long-term drainage [1]. We report the case of a 77-year-old patient failing conventional drainage with multiple plastic stents who presented with recurrent bouts of cholangitis and a newly developed intrahepatic cystic lesion ([Fig. 1])

Fig. 1 Magnetic resonance cholangiopancreatography showing a large intrahepatic cystic lesion (arrow) and dilated intrahepatic bile ducts.

An endoscopic ultrasound evaluation was performed that showed a large fluid collection in the left liver lobe with multiple intracystic nodules and dilated upstream bile ducts. We performed a cystogastrostomy with a 20-mm lumen-apposing metal stent (LAMS) to resolve the collection and improve biliary drainage ([Fig. 2]). On follow-up computed tomography imaging, cyst resolution was confirmed ([Fig. 3]) and the LAMS was extracted after one month, with subsequent bilateral intraductal radiofrequency ablation followed by placement of self-expandable metal stents into the left and right hepatic ducts ([Video 1]) through endoscopic retrograde cholangiography. At the one-year follow-up the patient was asymptomatic, having required only one additional endotherapy session with stent-in-stent placement of two plastic stents for recurring cholangitis due to stent ingrowth.

Fig. 2 Computed tomography (CT) scan showing a correctly placed 20-mm lumen-apposing metal stent (arrow) connecting the intrahepatic cyst and the stomach.

Fig. 3 Follow-up CT scan showing resolution of the cystic lesion with persistent dilatation (arrow) of the bile ducts.

The steps of the endoscopic “combined-arms approach” – endoscopic retrograde cholangiography and endoscopic ultrasound-guided drainage of the giant intraductal papillary mucinous neoplastic lesion of the bile duct.Video 1

This case highlights the importance of tailoring endoscopic solutions to address the unique challenges caused by inoperable IPMNs of the bile duct that may frequently require a progressive step-up in a “combined-arms” tactic, including both intraductal and transmural approaches to optimize biliary drainage.

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• Reference

• 1 Siiki A, Antila A, Vaalavuo Y. et al. Unconventional treatment of inoperable biliary IPMN with an oesophageal stent in the common bile duct: case report. Ther Adv Gastrointest Endosc 2023;