Direct Endoscopic Visualization via Cholangioscopy Before and After Radiofrequency Ablation

 

Patient History

An 83-year-old male patient originally presented with cholangitis (AST 158 U/l, ALT 214 U/l. Alkaline Phosphatase 490 U/l, Total bilirubin 7.1mg/dl) due to choledocholithiasis and 2cm irregular, distal bile duct stricture. Biopsies of the stricture were reported by pathology as ‘at least high-grade dysplasia (BilIN-3).’ Repeat biopsies suggested ‘suspicious for invasion’ with fluorescence in situ hybridization (FISH) analysis positive for Polysomy of Chromosomes 3, 7 and 17. Computed Tomography (CT) suggested no metastatic spread. Given his co-morbidities, he was deemed not a candidate for traditional therapies including medical management (chemotherapy and/or radiation) or surgical management. He was referred for consideration of endotherapy (radiofrequency ablation) using a Habib™ EndoHPB Bipolar Radiofrequency Catheter. In discussions with the patient, he desired aggressive endoscopic management, thus it was determined to schedule therapeutic interventions at regular intervals, and to use plastic stents in order to easily access the stricture.

 

Procedure

The patient underwent his first ablative procedure (Fig 4). Each ablation used ERBE settings: Bipolar soft (mode) Effect 8, Max Watts 10 with two treatments applied lasting 90 seconds with 60 second interval.

Cholangioscopy was used on each endoscopic procedure, in conjunction with traditional imaging (fluoroscopy), to better visualize (Fig. 1,2) the appearance and extent of the stricture before and after ablation (Fig 3,4). Repeat cholangioscopy and ablation were performed at 10 weeks and 24 weeks. Nine months following initial procedure, no ablation was necessary, directed biopsies with cholangioscopy were taken, CBD remains patent.

Following each endoscopic procedure, plastic biliary stenting (10Fr x 7cm plastic) was performed to ensure post procedure bile duct patency. The stent was then removed at each follow up exam to allow for a more comprehensive evaluation.

 

Outcome

The procedures have been tolerated well. Given the distal nature of stricture, he did have one episode of post ablation pancreatitis, which was mild. He is one year since original diagnosis. He has undergone a total of three ablative treatments. Given no clinical guidelines, he will be maintained in a close follow up protocol. Most recent CT has suggested no changes.

 

Conclusion

Treatment with radiofrequency ablation along with direct visualization of the stricture before and after the ablation and plastic stent placement may be useful for biliary decompression of strictures.