Successful biliary biopsy in a patient with surgically altered anatomy using a slim peroral cholangioscope via an endoscopic ultrasound-guided biliary drainage fistula

Endoscopic retrograde cholangiopancreatography (ERCP) can be performed in patients with surgically altered anatomy using a balloon-assisted enteroscope. However, postoperative adhesions and unique anatomical characteristics result in lower technical success rates, ranging from 75.8% to 94% ^{1 2 3} . Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been used after unsuccessful transpapillary biliary drainage attempts ^{4 5} . Nevertheless, obtaining a biopsy through an EUS-BD fistula remains technically challenging. This report presents a case where distal cholangiocarcinoma was diagnosed macroscopically and pathologically using a slim peroral cholangioscope (eyeMAX; Micro-Tech Co., Ltd., Tokyo, Japan) via an EUS-BD fistula.

A 66-year-old man with a history of Roux-en-Y reconstruction following gastric cancer resection presented with obstructive jaundice. Abdominal contrast-enhanced computed tomography revealed a stricture with circumferential wall enhancement in the distal bile duct ( Fig. 1 a ). Balloon endoscopy-assisted ERCP was attempted; however, adhesions prevented enteroscope insertion into the major papilla ( Fig. 1 b ). Consequently, EUS-BD was attempted. The bile duct was punctured with a 22-gauge needle. Cholangiography confirmed a distal bile duct stricture. A 7-Fr dedicated plastic stent was inserted through the fistula ( Fig. 1 c, d ). Considering the anticipated difficulty of the EUS-guided rendezvous technique due to adhesions, we attempted a biopsy via the EUS-BD fistula.

Fig. 1.

a Abdominal contrast-enhanced computed tomography showing a stricture (arrowhead) in the distal bile duct and a small, high-attenuation mass encircling the duct. b Balloon-assisted enteroscope failed to reach the papilla. c Fluoroscopic image showing a stricture in the distal bile duct. d A 15-cm 7-Fr dedicated plastic stent was inserted through the fistula.

One month later, we dilated the fistula using an ERCP catheter passed over the 7-Fr stent, allowing easy insertion of a 3.2-mm cholangioscope without additional balloon catheter dilation ( Video 1 ). The cholangioscope revealed a pinhole stricture with abnormal vascular proliferation in the distal bile duct ( Fig. 2 a ). Micro biopsy forceps were used to obtain specimens from the stricture ( Fig. 2 b, c ). The position of the stricture was confirmed fluoroscopically. Following cholangioscope withdrawal, additional biopsy specimens were acquired using an ERCP guide sheath (Olympus Medical, Tokyo, Japan) ( Fig. 2 d, e ). No procedure-related adverse events occurred. Both biopsy specimens indicated adenocarcinoma, and surgical intervention was scheduled ( Fig. 2 f ).

Fig. 2.

a The distal bile duct was pinhole-shaped and had abnormal vascular proliferation. b Biopsy forceps used with the slim peroral direct digital cholangioscope (eyeMAX; Micro-Tech Co., Ltd., Tokyo, Japan). c The stricture site was identified endoscopically, and a biopsy was performed. d The biopsy forceps were deployed through an endoscopic retrograde cholangiopancreatography guide sheath (Olympus Medical, Tokyo, Japan). e Biopsy specimens were obtained from the stricture site under fluoroscopic guidance. f Biopsy specimens showed adenocarcinoma.

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Biliary biopsy was successfully performed in a patient with surgically altered anatomy using a slim peroral cholangioscope through an endoscopic ultrasound-guided biliary drainage fistula.

Video 1

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