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DOI: 10.1055/a-2545-2606
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])
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.
Quality:
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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Conflict of Interest
Theodor Voiosu and Bogdan Mateescu have received speaker fees from Boston Scientific. All other authors have no COI to declare.
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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;
Correspondence
Publication History
Article published online:
12 March 2025
© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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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;