S2379 A Unique Approach in Selective Guidewire Cannulation of a Complex Malignant Biliary Stricture

Abstract

INTRODUCTION: Digital single-operator cholangioscopy (D-SOC), such as Spyglass DS, represents newer technology that can improve the diagnostic and therapeutic capabilities of ERCP. In the case below, we present how the use of Spyglass aided in the decompression of a complex malignant biliary stricture. CASE DESCRIPTION/METHODS: 52 year old male presented with epigastric pain, and obstructive jaundice. Patient has known portal vein thrombosis, and metastatic adenocarcinoma to the liver and lungs. The primary is suspected to be of upper GI or pancreatobiliary origin.CBC, PT INR, and BMP were within normal limits. T Bili is 17 mg/dL, D Bili 12.5 mg/dL, Alk Phos 1441 units/L, AST 300 units/L, ALT 251 units/L, AFP 11.5 ng/mL, CEA 249.8 ng/mL, and CA 19–9 113,888 units/mL. MRCP: Abrupt cut off of the distal common hepatic duct with intrahepatic bile duct dilatation.ERCP found 2 high grade biliary strictures. Conventional guidewire cannulation of the strictures were unsuccessful.A second ERCP was performed with the aid of Spyglass DS. Under direct visualization from Spyglass and fluoroscopy, guidewire cannulation of the high-grade common bile duct and hepatic duct strictures were achieved. A fully covered 10 Fr x 80mm metal stent was advanced over the guidewire and deployed across both strictures. Then, the waist of the stent was balloon dilated to 6 mm. Biliary drainage was confirmed upon scope retraction. Patients bilirubin downtrended and he was discharged with oncology follow up. DISCUSSION: The incidence of malignancy related biliary obstruction is increasing. The majority of these patients will benefit from biliary decompression in order to improve quality of life. Given the complications associated with percutaneous transhepatic biliary drains and stenting of biliary strictures, therapeutic ERCP is the favored approach. However, even the most experienced endoscopists fail to cannulate malignant strictures 5-10% of the time with conventional ERCP. Based on our experience, the utility of Spyglass DS might be of benefit when managing difficult malignant biliary strictures. Upon our literature review, the use of D-SOC guided cannulation of these strictures were found in only 11 patients, with 64% having cholangiocarcinoma. With the aid of D-SOC, the success rate of cannulation was 46%. Given limited literature, more research for this procedural indication should be considered as D-SOC could be a viable approach in improving the effectiveness of endoscopic management of these complex malignant strictures.