A 77-year-old man was admitted for evaluation of recurrent episodes of cholangitis.
He had undergone endoscopic retrograde cholangiography (ERC) several times for biliary
stone disease and for cholecystectomy, and suffered from advanced Alzheimer disease.
Abdominal magnetic resonance imaging (MRI) revealed dilatation of the right posterior
intrahepatic duct ([Fig. 1]), with aberrant drainage directly into the common hepatic duct. However, multiple
attempts to reach this segment by ERC were unsuccessful ([Fig. 2]). The Spyglass system was then used for selective opacification ([Fig. 3]) and optical viewing of the aberrant bile duct (Boston Scientific, Natick, Massachusetts,
USA) [1]
[2]. A reddish nodular lesion was seen obstructing the lumen ([Fig. 4]), and targeted biopsies with a 3-Fr Spybite mini-forceps (Boston Scientific) confirmed
the presence of an adenoma ([Fig. 5]) [3]. The stricture was dilated with a Hurricane 8-mm, 4-cm balloon (Boston Scientific)
and the stones were extracted. The Spyscope was removed and two 7-Fr plastic stents
placed. Given the patient’s poor mental and general status, we proposed carrying out
endobiliary radiofrequency ablation of the stricture. This was done 4 weeks later
with a wire-guided Habib EndoHPB (Emcision, London, UK) ([Fig. 6]) [4]. This case illustrates the potential impact of selective cholangioscopy with the
Spyglass system on diagnosis and management of indeterminate biliary strictures.
Fig. 1 Magnetic resonance imaging (MRI) showing dilatation of the right posterior hepatic
duct, without visible cause of obstruction, in a 77-year-old man with history of recurrent
episodes of cholangitis.
Fig. 2 Failure to opacify the aberrant right hepatic duct with classical filling techniques
during endoscopic retrograde cholangiography (ERC).
Fig. 3 Targeted access to the aberrant posterior right bile duct with the Spyglass system
showing tumoral obstruction.
Fig. 4 Optical viewing of the aberrant bile duct with the Spyglass system showing a nodular
lesion obstructing the lumen.
Fig. 5 Histological section of the biliary adenoma, characterized by the regular sheets
of monotonous cells, with monomorphic nuclei localized to the bottom of the cytoplasm
(Papanicolaou stain; magnification × 25).
Fig. 6 Guide wire inserted through the biliary stenosis (left) and a Habib EndoHPB catheter
placed at the level of the intraductal adenoma (right).
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