Is It a Bird? Is It a Plane? It's a Tumour – Operative Transcystic Choledochoscopy for Differentiation of Biliary Duct Filling Defect and New Early Diagnosis of Insidious Pancreatic Adenocarcinoma

Abstract

Background: Operative Transcystic Choledochoscopy (OTC) during Laparoscopic Cholecystectomy (LC) is a one-procedure solution for clearance of Common Bile Duct (CBD) calculi under vision and allows identification and biopsy of biliary neoplasms. Success and complication rates in high-volume centres are similar or superior to Endoscopic Retrograde Cholangiopancreatography (ERCP). Preference for ‘minimally-invasive’ techniques like ERCP has led to infrequent use and resultant deskilling. Its ongoing role is therefore currently unclear. Case: A well 65-year-old male with epigastric pain and raised lipase, and Computed Tomography (CT) showing cholelithiasis and ‘focal pancreatitis involving the uncinate process’, underwent LC for gallstone-induced pancreatitis 6 days after presentation. Pre-operative bilirubin was normal and ALKP (133 U/L) and GGT (270 U/L) newly raised. An oedematous stone-containing gallbladder and a distal CBD filling defect on Intraoperative Cholangiogram were found. OTC demonstrated a CBD wall growth but biopsy equipment was unavailable. No peritoneal or liver metastases were seen. Ca19.9 (588 kU/L) was elevated. Pancreas-protocol CT/MRI showed a 14x14mm ‘indeterminate abnormality’ in the head/uncinate process without vascular involvement, and staging CT was negative for metastases. Endoscopic Ultrasound-guided biopsy diagnosed pancreatic adenocarcinoma following non-diagnostic ERCP. A Whipple’s procedure was planned but later abandoned as liver metastases were confirmed on frozen section at staging laparoscopy. Discussion: Despite recent movement away from OT during LC, this study highlights its utility in early identification of insidious biliary neoplasmswith the first case of preliminary pancreatic adenocarcinoma diagnosed with OTC during LC in a non-obstructed patient.