PERCUTANEOUS CHOLANGIOSCOPY-ASSISTED ANTEGRADE GUIDEWIRE CANNULATION AND
METAL STENTING IN DIFFICULT PERIAMPULLARY MALIGNANCY
RGG Bondoc; KJS Cham; LBC Corral; EG Ong Metropolitan Medical Center
Significance: Failed endoscopic cannulation of ampullary tumors is a challenge and biliary drainage either percutaneously or surgically, is the next best option. For certain patients undergoing percutaneous transhepatic biliary drainage (PTBD), internal drainage is difficult due to failure to bypass the ampullary obstruction. Percutaneous cholangioscopy provides direct visualization of the obstruction and may help to traverse the stenosis.
Clinical Presentation: A 60-year-old lady developed jaundice, melena and weight loss. There was anemia at 78 g/dl and hyperbilirubinemia at 8.06mg/dl. CT scan showed periampullary mass, dilated biliary tree and hepatic metastasis. ERCP failed to identify the papillary ostium in the bleeding ulcerating lesion.
Management: PTBD was done for decompression. After two weeks, PTBD revision with guidewire failed to bypass the distal stricture. A cholangioscope was percutaneously inserted and the stenosis identified and the wire tunneled into the duodenum. The stricture was dilated followed by deploymentof a Boston Scientific fully covered biliary self-expanding metal stent (SEMS) under fluoroscopic and per-oral endoscopic view. The following day showed a fully-expanded metal stent. Her jaundice gradually improved.
Recommendation: Percutaneous cholangioscopy–assisted guidewire cannulation into the stenosis has successfully converted a difficult PTBD into an internal drainage with SEMS deployment. This may be offered in patients with PTBD with failed cannulation of distal or ampullary stenosis where guidewire cannot bypass it under fluoroscopy.
Keywords: Case report, percutaneous cholangioscopy, malignant biliary strictures