Repeat Radiofrequency Ablation Treatment Combined with Stone Lithotripsy to Maintain Biliary Drainage

 

Patient History

A 39-year-old male was admitted to Presence St. Mary & Elizabeth Hospital for jaundice, weight-loss and right upper quadrant pain. CT imaging suggested a stricture at the bifurcation. Patient was referred to GI for ERCP.

 

Procedure

The common bile duct was accessed using a Jagtome™ RX 39 Cannulation Sphincterotome, and a balloon-occluded cholangiogram was performed (Fig. 1). The cholangiogram displayed a large filling-defect at the bifurcation, with no dye in either of the hepatics. SpyGlass™ DS Direct Visualization System was sent over the guidewire, into the common bile duct (Fig. 2). Upon arrival at the bifurcation, the area was strictured. SpyBite™ Biopsy Forceps were used to extract tissue for biopsy, and pathology confirmed a diagnosis of cholangiocarcinoma. A plastic stent was placed for further patient evaluation. The patient was found to have metastatic disease and was not a surgical candidate.

The patient was brought back ten weeks after the index procedure for common hepatic-duct, radiofrequency ablation (RFA). The stricture was visualized with the SpyScope™ DS Catheter, marked on fluoroscopy, and ablated with the Habib™ EndoHPB Bipolar Radiofreqency Catheter. The catheter was placed over a guidewire and traveled smoothly into the CBD. Two ablation sessions were performed, moving proximal to distal in location. Upon completion of RFA, margins were confirmed with the SpyScope DS Catheter, and a plastic stent was placed (Fig. 3).

 

Outcome

The patient did not experience any complications and returned to the hospital eight weeks later for repeat intervention. Stricture resolution was observed, with the hepatic ducts working in congruence and in a larger diameter (Fig. 4). The patient did not receive palliative chemotherapy. A similar algorithm was followed from the first case, however this time several large stones were filling the intrahepatics (Fig. 5). It is believed that the first RFA session enabled biliary drainage, allowing for the stones to pass through. Electrohydrolic Lithotripsy (EHL) was performed to eliminate the stones from the duct. Residual debris was cleared with an Extractor™ Pro Retrieval Balloon Catheter. RFA was then performed in the same areas, two sessions moving proximal to distal. Plastic stent was placed for further evaluation.

 

Conclusion

Eleven weeks later, the patient returned for another RFA intervention. Improvement to the biliary tree was observed from both the SpyScope™ DS Catheter and X-Ray imaging. A third RFA procedure was performed with the Habib™ EndoHPB Bipolar Radiofrequency Catheter and the patient has shown improvement in biliary drainage from the initial presentation.