1384 Expanding the Horizons of Endoscopy: Cholangioscopy and Radiofrequency Ablation via Percutaneous Transhepatic Biliary Drainage

Abstract

INTRODUCTION: A variety of transhepatic percutaneous biliary interventions are applicable for the management of biliary system pathologies, including: percutaneous transhepatic cholangiogram (PTC), percutaneous transhepatic biliary drainage (PTBD), and percutaneous transhepatic cholangioscopy (PTCS). These methods are useful to visualize the biliary system for diagnostic and/or therapeutic purposes; however they are generally reserved when endoscopic retrograde cholangiopancreatogram (ERCP) or peroral cholangioscopy is unsuccessful or not feasible. We present a novel approach in the management of malignant hilar biliary obstruction (MHBO). CASE DESCRIPTION/METHODS: A 63-year-old male with history of decompensated HCV/EtOH cirrhosis presented with painless jaundice, weight loss, and CT/MRI findings suggested hepatic mass with biliary duct dilation, concerning for hilar cholangiocarcinoma. Interventional Radiology (IR) performed PTC and then PTBD to decompress the biliary tree and placed external bilateral biliary drains. Our Role: With assistance from IR, PTCS was performed with evidence of malignant hilar biliary obstruction however, cytology and biopsies were negative for malignancy. CT guided percutaneous hepatic mass biopsy was reported as poorly differentiated adenocarcinoma. PTCS was again performed with evidence of right-sided malignant stricture and subsequently RFA (RFA catheter with 8 F bipolar probe (soft mode effect of 8-10 watts) and two ring electrodes (8 mm long and 6 mm apart) with ablation length of 25 mm ± 3 mm) of right and left hepatic biliary duct was performed under fluoroscopy guidance (3 cycles). Biliary drains were removed and bilateral biliary stents were placed. Post ablation PTCS showed excellent ablation of malignant tissue and patent ducts on PTC. Excellent toleration and no post-procedural symptoms were reported. DISCUSSION: Malignant biliary tumors are often unresectable. Biliary RFA using the bipolar radiofrequency catheter is a new endoscopic therapy for malignant or benign tissue in the pancreatic and biliary tract. This novel approach for PTC/RFA via PTBD provides an alternative for the management of biliary tract obstruction whenever ERCP and peroral cholangioscopy guided treatments are not feasible.