Peroral cholangioscopy in patients with altered gastrointestinal
anatomy is challenging because of the technical difficulties associated with
accessing the papilla and the high rate of complications experienced when using
a side-viewing duodenoscope [1]. The recently developed
SpyGlass Direct Visualization System (Microvasive Endoscopy, Boston Scientific,
Natick, Massachusetts, USA) can be passed through a forward-viewing endoscope
because its diameter is 10 Fr [2]
[3]
[4]. We describe a case of
cholangiocarcinoma that was successfully visualized using a SpyGlass
cholangioscope in a patient with a Billroth II gastrectomy.
An 81-year-old man presented to our institution for evaluation of
obstructive jaundice. His medical history included a Billroth II gastrectomy
for gastric cancer 10 years previously. A front-viewing endoscope was passed
through the afferent limb reaching the papilla without difficulty. A
cholangiogram showed a severe stricture at the lower end of the bile duct ([Fig. 1]).
Fig. 1 Cholangiogram showing a
stricture at the lower end of the bile duct.
Following endoscopic papillary balloon dilation, a SpyGlass
cholangioscope was passed into the bile duct without difficulty ([Fig. 2]).
Fig. 2 Fluoroscopy showing the
SpyGlass cholangioscope inside the bile duct, having been passed through the
forward-viewing endoscope.
Cholangioscopy showed an irregular, fine granular lesion at the
upper end of the stricture and normal mucosa at the hilar bile duct ([Fig. 3]), both of which were biopsied under
cholangioscopic imaging using a 3-Fr SpyBite forceps (Boston Scientific;
[Video 1]).
Fig. 3 Cholangioscopy showing:
a an irregular, fine granular lesion at the upper end of
the stricture; b normal mucosa at the hilar bile
duct.
Qualität:
Video
1 SpyGlass cholangioscopy
showing the lesion at the upper end of the stricture and the normal hilar bile
duct followed by a biopsy being taken with the SpyBite forceps.
The biopsy specimens taken from the irregular lesion showed
adenocarcinoma, whereas those from the hilar bile duct showed no malignancy. He
was diagnosed as having a lower bile duct carcinoma without intraepithelial
spread of tumor to the hilar bile duct and underwent pancreatoduodenectomy at
our hospital.
Peroral cholangioscopy with mapping biopsies has been shown to be
effective for the diagnosis of intraepithelial tumor spread in
cholangiocarcinoma [5]. Although SpyGlass cholangioscopy
through a colonoscope has been reported in patients with a Roux-en-Y
anastomosis [3]
[4], to our
knowledge, this is the first case of bile duct biopsy under direct
visualization by SpyGlass cholangioscope in a patient with a Billroth II
gastrectomy. In summary, SpyGlass cholangioscopy through a forward-viewing
endoscope was very useful for the diagnosis of cholangiocarcinoma in a patient
with a Billroth II gastrectomy.
Endoscopy_UCTN_Code_TTT_1AR_2AB
