Published online Oct 20, 2020. doi: 10.5412/wjsp.v10.i2.3
Peer-review started: June 18, 2020
First decision: July 25, 2020
Revised: August 23, 2020
Accepted: September 25, 2020
Article in press: September 25, 2020
Published online: October 20, 2020
Cholangioscopy has been described in case reports and series to facilitate guidewire placement in difficult benign biliary strictures. Specifically, it has been infrequently used in difficult benign anastomotic liver transplant biliary strictures to visualize the stricture orifice for guidewire placement. 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 jaundice and weight loss. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) by other endoscopists demonstrated pancreatic adenocarcinoma with a dilated cystic duct (CD) and proximal common bile duct (CBD). The associated distal CBD stricture was dilated and stented with a plastic stent. However she subsequently developed cholangitis, prompting referral for a repeat ERCP. The stent was found to have migrated distally to the confluence of the dilated CD and CBD stricture. Despite using multiple hydrophilic guidewires, the stricture could not be traversed due to preferential wire passage into the dilated CD. SpyGlass DS (Boston Scientific Corp, Marlborough, MA, United States) was then used to visualize the orifices of the CD and CBD stenosis, enabling the guidewire to be placed directly through the stricture into the proximal CBD. A WallFlex covered metal stent (Boston Scientific Corp, Marlborough, MA, United States) was successfully placed, resulting in resolution of her cholangitis.
To our knowledge, this is one of the first cases to describe successful cholangioscopic guidewire placement for malignant biliary strictures.
Core Tip: Cholangioscopy has been described in case reports and series to facilitate guidewire placement in difficult benign biliary strictures, especially in the setting of liver transplants. Most biliary strictures are successfully traversed with standard techniques utilizing hydrophilic guidewires during endoscopic retrograde cholangiopancreatography, but challenges with difficult wire placement can occur when the biliary tree consists of multiple strictures and sharp angulations. Here we describe a case of guidewire placement through a difficult malignant biliary stricture using single operator cholangioscopy, highlighting the versatility of cholangioscopy especially in anatomically challenging patients.