Diagnosing Cholangiocarcinoma using Cholangioscopy and Treating a Duodenal Ulcer with Physician-controlled Clip Rotation

 

Patient History

An 87-year-old-male presented with painless jaundice, decreased appetite, dark urine, weight loss, and clay color stool for 2 weeks. The patient underwent lab work and a CT scan which revealed moderate-to-severe intrahepatic bile duct dilation, three lesions in the liver, and local lymphadenopathy. The distal common bile duct imaging was normal.

Procedure

The patient was set up for an ERCP. An occlusion cholangiogram was taken and a 1cm stricture was identified above the cystic take-off at the common hepatic duct (Figure 1). The stricture was evaluated under direct visualization using the SpyGlass™ DS System (Figure 2). The tumor was friable with neo-vascularity and luminal narrowing, which was focal to the common hepatic duct (Figures 3 and 4).

Targeted biopsies were performed under direct visualization. A varying number of biopsies were taken each pass, depending on the biopsy tissue captured in the SpyBite™ Biopsy Forceps. After each biopsy pass, the cellular rich aspirate was suctioned from the duct, followed by targeted bile duct brushings using the visual impression of the SpyScope™ DS Catheter as our guide.

We identified the exact margins of the tumor using the SpyGlass DS System, which led us to place a 10Fr x 9cm stent that extended above the common hepatic duct stricture.

At the start of the case, while passing the duodenal scope into position for the ERCP, a visible vessel duodenal ulcer was observed at the D1/D2 transition. The ulcer was not bleeding, so it was treated after the ERCP was complete. An EGD scope was used and combination therapy was implemented to treat the ulcer (less than 1.5cm). Thermal therapy with a 7Fr Injection Gold Probe™ Catheter was utilized followed by mechanical hemostasis with the placement of two Resolution 360™ Clips (Figure 5). A stable scope position and clip control are often challenging at that anatomical location. The Resolution 360 Clip with physician-controlled rotation was used to orient the clip into position.

Outcome and Discussion

The next day, the patient’s LFTs and bilirubin counts were cut in half and his appetite improved.

 Pathology from the SpyGlass DS System biopsies confirmed adenocarcinoma, as did cellular aspirate which had malignant epithelial cells (Figure 6).

Due to the patient’s age, metastatic disease, and co-morbidities, he was referred to hospice. The SpyGlass DS System enabled a diagnosis in one procedure, which led to the decision of palliative treatment for the patient. Follow-up procedures will most likely be unnecessary do the effectiveness of this ERCP using the SpyGlass DS System.