ASGE DDW Videos from Around the World | 2024-PERCUTANEOUS TRANSHEPATIC CHOLANGIOSCOPY FOR EHL LITHOTRIPSY AFTER PANCREAS-PRESERVING DUODENECTOMY: AN UNEXPECTED FINDING

Video Transcription

A 79-year-old patient was admitted to our department with cholangitis, presenting with rigors, right upper quadrant pain, jaundice,  raised cholestatic liver enzymes. His past medical history includes pancreas-preserving duodenectomy, forefathers' ampullary laterally spreading tumor five years ago.  At that time, a frozen histology of the surgical specimen had shown low-grade displays and focal high-grade  ampullary adenoma, and a very short segment of 5-millimeter distal CBD was resected as well, and this was adenoma-free, finally leading to Rouen Y anatomy. During the current  mission, the patient underwent a CT scan that shows a healthy hepatico-jejunal anastomosis with a 2-centimeter biliary stone above the anastomosis  and with upstream biliary dilatation. The mid-CBD was 3.4 centimeters approximately, and significant interhepatic biliary dilatation was  seen. The patient has ICD in place and could not undergo MRCP. In view of altered anatomy and of a long hepatico-jejunal loop seen on the CT scan,  anterograde ERC was deemed impossible, and as such, percutaneous transhepatic cholangiography was performed instead, confirming a large filling defect above the anastomosis.  Balloon dilatation of the anastomosis took place, followed by unsuccessful radiological attempts to push the stone distally.  Percutaneous transhepatic cholangioscopy with a dedicated short single-use cholangioscope, spyglass discover, was then performed, showing a large biliary stone,  electrohydraulic lithotripsy was applied, fragmenting the stone in small pieces that were easily flushed down into the small bowel loop.  Interestingly, following that, a large, approximately 12 millimeter in diameter, choledochal adenomatous polyp was seen just above the anastomosis.  Biopsies were taken from this polyp that have finally shown enteric type choledochal tubulovilus adenoma with low-grade dysplasia.  An external internal percutaneous transhepatic train was left in place, in a good position and working well. The patient had an uneventful stay,  with almost normalization of his cholestatic biochemistry, 14 days following the procedure.

Video Summary

A 79-year-old patient with a history of previous surgeries presented with cholangitis and complications including a biliary stone and biliary dilatation. Due to the patient's altered anatomy, traditional procedures were not possible, so percutaneous transhepatic cholangiography and lithotripsy were performed successfully. An adenomatous polyp was also discovered above the anastomosis during the procedure. Biopsies confirmed low-grade dysplasia. The patient responded well to treatment, and a percutaneous transhepatic drain was left in place. Following the procedure, the patient's cholestatic biochemistry improved significantly.

Asset Subtitle

Andreas Koutsoumpas

Keywords

cholangitis

biliary stone

biliary dilatation

percutaneous transhepatic cholangiography

adenomatous polyp