Percutaneous antegrade digital cholangioscopy in the management of biliary disorders

Cholangioscopy is a helpful tool in the evaluation of biliary disorders, with indeterminate biliary strictures and large bile duct stones being the most common indications. Advances in cholangioscope technology have led to improvements in visualization and scope maneuverability. Cholangioscopy is most frequently used during ERCP; however, biliary access through ERCP may be limited because of postsurgical anatomy. With the assistance of interventional radiologists, gastroenterologists can use digital cholangioscopy in a percutaneous antegrade route to facilitate the evaluation of biliary disorders. We describe this approach in 2 cases (Video 1, available online at www.VideoGIE.org). In both cases, percutaneous biliary access was obtained by interventional radiology, and a 12F angiosheath was advanced to the intrahepatic bile duct. The cholangioscope was passed antegrade through the sheath. A percutaneous biliary drain was replaced at the conclusion of the procedure. All patients received periprocedural antibiotics.

The first patient was a 77-year-old woman with a prior liver transplant who experienced multiple ischemic biliary strictures requiring long-term percutaneous biliary drains. She experienced recurrent cholangitis, and a cholangiogram revealed a large filling defect at the bifurcation consistent with a stone (Fig. 1A, arrow at filling defect). Standard ERCP was not attempted because the patient already had indwelling bilateral percutaneous catheters. Percutaneous antegrade cholangioscopy demonstrated a large stone at the confluence (Fig. 1B), and electrohydraulic lithotripsy was successful in fracturing the stone. Subsequently, a balloon catheter was then used to sweep the remaining fragments antegrade into the bowel (Fig. 1C). Cholangitis has not recurred.

Figure 1.

A, Cholangiogram demonstrating a filling defect (arrow). B, Cholangioscopic view demonstrating a large stone at the confluence, partially occluding the lumen. C, Cholangioscopic view demonstrating a balloon sweeping stone fragments antegrade through the hepatic duct. D, Cholangioscopic view at the level of the confluence demonstrating ulcerated and erythematous tissue with superficial dilated and tortuous blood vessels, consistent with malignancy. E, Cholangioscopic view at the level of the confluence demonstrating severe stricture of the common hepatic duct, and abnormal mucosa with dilated and tortuous blood vessels, consistent with malignancy. F, Cholangioscopic view at the level of the confluence demonstrating prominent dilated and tortuous blood vessels, consistent with malignancy.

The second patient was a 72-year-old man with a prior Whipple resection for pancreatic cancer who presented with jaundice 2 years after surgery. Imaging was suggestive of recurrence at the biliary anastomosis. An initial ERCP was unsuccessful at reaching the hepaticojejunostomy despite the use of both a pediatric colonoscope and a single-balloon enteroscope because of multiple sharp angulations and bowel tethering. A percutaneous transhepatic catheter was placed for biliary decompression, but tissue was still needed to guide care. Cholangioscopy demonstrated a malignant-appearing stricture at the biliary anastomosis (Figs. 1D-F). Examination of biopsy specimens confirmed recurrent adenocarcinoma. He ultimately elected to forgo further treatment and went home to receive hospice care.

Disclosure

All authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Antegrade percutaneous cholangioscopy and electrohydraulic lithotripsy of a biliary stone (case 1). Antegrade percutaneous cholangioscopy used to obtain intrahepatic tissue (case 2).