Cholangioscopy-Assisted Guidewire Placement in a Malignant Biliary Stricture

Abstract

Cholangioscopy is an adjunct to fluoroscopic evaluation during endoscopic retrograde cholangiopancreatography (ERCP), with uses ranging from diagnostic evaluation of strictures to therapeutic lithotripsy of stones. However, cholangioscopy has not been described previously to assist guidewire placement in malignant biliary strictures. Here we describe a case of guidewire placement through a difficult malignant biliary stricture using single operator cholangioscopy. A 74-year-old female presented with painless jaundice and weight loss. Endoscopic ultrasound (EUS) and ERCP by other endoscopists demonstrated pancreatic adenocarcinoma with a markedly dilated cystic duct (CD) and common bile duct (CBD). The associated distal CBD stricture was initially dilated and stented. However, the patient persisted to have jaundice and subsequently developed cholangitis two days later, prompting a referral for a repeat ERCP. The previously-placed biliary stent migrated distally to the confluence of the markedly dilated cystic duct and high-grade CBD stricture (Figure 1). Despite using multiple hydrophilic guidewires, the stricture could not be traversed due to preferential wire passage into the dilated cystic duct. Cholangioscopy was then used to visualize the orifices of the CD and CBD stenosis (Figure 2), enabling the guidewire to be placed directly through the stricture into the proximal CBD (Figure 3). A covered metal stent was successfully placed in the CBD, resulting in the resolution of the patient's cholangitis and jaundice. Most biliary strictures are successfully traversed with standard techniques using hydrophilic guidewires during ERCP, but challenges can occur when the biliary tree consists of multiple strictures and sharp angulations. Cholangioscopy provides direct visualization of the ducts which can allow wire access to a selective duct, significantly increasing success rate and preventing repeat procedures. This method has been described previously in difficult anastomotic strictures in liver transplant patients, with technical success. To our knowledge, this is the first case to describe guidewire placement using cholangioscopy for a malignant biliary stricture. Cholangioscopy is an effective tool for accurate guidewire placement in difficult benign and malignant biliary strictures and can be considered in anatomically challenging patients.2118_A Figure 1. Dilated cystic duct with looped guidewire.2118_B Figure 2. Direct visualization of CBD stenosis with guidewire (arrow) and dilated cystic duct (asterisk).2118_C Figure 3. Successful placement of guidewire in CBD (arrow).