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Direct visualization of biliary stricture through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy
VIDEOGIE Todd H. Baron, MD, G. S. Raju, MD, Editors for VideoGIE
Direct visualization of biliary stricture through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy
Figure 1. Biliary stricture after Roux-en-Y hepaticojejunostomy. A, MRCP showing a stricture (arrow) at the confluence of the hepatic ducts. B, Cholangioscope (OD, 3.3 mm; WL, 2300 mm; WC, 1.2 mm) can be easily introduced through the working channel of the adult colonoscope (OD, 13.2 mm; WL 1680 mm; WC, 3.7 mm). C, Colonoscope-assisted cholangioscopic view showing multiple stones impacted in the hepatic duct. D, A benign inflammatory stricture with no suspicious features is seen around the stones.
Bile duct visualization in surgically altered anatomy can be challenging. We describe a simple technique of colonoscope-assisted cholangioscopy (CAC) to evaluate a biliary stricture in a patient with Roux-en-Y hepaticojejunostomy (RYHJ). A 57-year-old man with a history of distal common bile duct cholangiocarcinoma presented with abdominal pain and weight loss. He had undergone RYHJ 5 years earlier and was in remission. His liver tests showed cholestasis (bilirubin 35 mmol/L, alkaline phosphatase 2215 U/L). The MRCP showed a stricture suggestive of recurrence at the hepatic duct confluence. We performed ERCP with use of a pediatric colonoscope (Olympus, PCF-PH 190, Center Valley, Pa): outer diameter 9.7 mm, working length 1680 mm, working channel 3.2 mm, equipped with cap and water-jet function. By maintaining a straight colonoscope, we cannulated the duct and dilated the stricture. We performed brush cytology to exclude metachronous cholangiocarcinoma and placed a plastic stent (8.5F) for drainage. Cytologic assessment showed atypical cells. We repeated the procedure using an adult colonoscope (Olympus, CF-HQ190A/L) and introduced a cholangioscope (Spyglass-DS, Boston Scientific, Marlborough, Mass) through the working
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channel (Fig. 1; Video 1, available online at www. giejournal.org). The presence of the stent enabled the cholangioscope to advance further into the bile duct. Cholangioscopy showed a benign stricture without worrisome features and multiple stones, which were removed, resulting in symptom resolution. In conclusion, CAC can be performed in RYHJ to enable a precise diagnosis. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Ravishankar Asokkumar, MBBS, MRCP, Damien Tan, MBBS, MRCP, Christopher Khor, MBBS, FRCP, FAMS, FASGE, Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Roy Soetikno, MD, FASGE, Department of Gastroenterology and Hepatology, Singapore General Hospital, National Cancer Center Singapore, Duke-NUS Medical School, Singapore http://dx.doi.org/10.1016/j.gie.2016.03.1492
Volume
-,
No.
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: 2016 GASTROINTESTINAL ENDOSCOPY 1
Direct visualization of biliary stricture through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy
Figure 1. Biliary stricture after Roux-en-Y hepaticojejunostomy. A, MRCP showing a stricture (arrow) at the confluence of the hepatic ducts. B, Cholangioscope (OD, 3.3 mm; WL, 2300 mm; WC, 1.2 mm) can be easily introduced through the working channel of the adult colonoscope (OD, 13.2 mm; WL 1680 mm; WC, 3.7 mm). C, Colonoscope-assisted cholangioscopic view showing multiple stones impacted in the hepatic duct. D, A benign inflammatory stricture with no suspicious features is seen around the stones.
Bile duct visualization in surgically altered anatomy can be challenging. We describe a simple technique of colonoscope-assisted cholangioscopy (CAC) to evaluate a biliary stricture in a patient with Roux-en-Y hepaticojejunostomy (RYHJ). A 57-year-old man with a history of distal common bile duct cholangiocarcinoma presented with abdominal pain and weight loss. He had undergone RYHJ 5 years earlier and was in remission. His liver tests showed cholestasis (bilirubin 35 mmol/L, alkaline phosphatase 2215 U/L). The MRCP showed a stricture suggestive of recurrence at the hepatic duct confluence. We performed ERCP with use of a pediatric colonoscope (Olympus, PCF-PH 190, Center Valley, Pa): outer diameter 9.7 mm, working length 1680 mm, working channel 3.2 mm, equipped with cap and water-jet function. By maintaining a straight colonoscope, we cannulated the duct and dilated the stricture. We performed brush cytology to exclude metachronous cholangiocarcinoma and placed a plastic stent (8.5F) for drainage. Cytologic assessment showed atypical cells. We repeated the procedure using an adult colonoscope (Olympus, CF-HQ190A/L) and introduced a cholangioscope (Spyglass-DS, Boston Scientific, Marlborough, Mass) through the working
www.giejournal.org
channel (Fig. 1; Video 1, available online at www. giejournal.org). The presence of the stent enabled the cholangioscope to advance further into the bile duct. Cholangioscopy showed a benign stricture without worrisome features and multiple stones, which were removed, resulting in symptom resolution. In conclusion, CAC can be performed in RYHJ to enable a precise diagnosis. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Ravishankar Asokkumar, MBBS, MRCP, Damien Tan, MBBS, MRCP, Christopher Khor, MBBS, FRCP, FAMS, FASGE, Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Roy Soetikno, MD, FASGE, Department of Gastroenterology and Hepatology, Singapore General Hospital, National Cancer Center Singapore, Duke-NUS Medical School, Singapore http://dx.doi.org/10.1016/j.gie.2016.03.1492
Volume
-,
No.
-
: 2016 GASTROINTESTINAL ENDOSCOPY 1