Cholangioscopy with laser recanalization to enable internal biliary drainage. Primary author, Andrew Y. Wong. Co-authors, Curtis K. Argo, Duchant S. Uppel, Daniel S. Strand, Andre B. Ufflacher. These are our disclosures. A 58-year-old woman with history of alcohol-associated child's PU class C cirrhosis with relatively low MELD, complicated by portal hypertension, ascites, encephalopathy, and non-bleeding esophageal varices presented with biliary obstruction, biloma, and high-output percutaneous biliary drainage. She had an enlarging 1.9-centimeter enhancing Lyrads IV liver lesion in segment IVa and underwent CT-guided percutaneous microwave ablation two years ago. Contrasted MR imaging showed an enhancing lesion in the left lobe of the liver. Under CT guidance, microwave ablation of the hepatic segment IV lesion was performed. Delayed arterial phase CT imaging demonstrated the immediate post-microwave ablation effect. The woman was successful but complicated by recurrent abscess and biloma in the left liver that required a percutaneous transepatic biliary drain that could not be internalized due to lack of communication with the left or common hepatic ducts. Three days before this feature procedure, she presented in metabolic disarray and with acute hypovolemic kidney injury from high-output biliary drainage and required ICU-level care. She has had several other admissions due to dehydration. MR imaging almost two years after ablation and approximately six weeks prior to presentation demonstrated a persistent biloma and biliary dilation. Percutaneous cholangiogram one month prior to presentation demonstrated biliary dilation and a biloma in the left liver with no communication with the extrahepatic biliary tree. Prior to her admission, an attempt at a joint endoscopic interventional radiology rendezvous procedure had been electively planned. As IR attempts had not been successful, if conventional ERCP techniques at wire access failed, we had discussed methods at recanalizing the ducts meant to drain the area of the biloma, including use of cholangioscopy and holmium YAG laser therapy. The holmium YAG laser we use in endoscopy has FDA 510K premarket clearance for surgical procedures requiring endoscopic ablation, vaporization, excision, incision, and coagulation of soft tissue. During biliary lithotripsy, focusing laser light of a high-power density on the surface of a stone creates a plasma bubble that oscillates and induces cavitation. The laser's plasma bubble also enables work on soft tissue. In a benchtop demonstration, the power of a 20-watt GI handling laser is demonstrated. With a few pulses, the laser creates a 2-millimeter sized hole through the cardboard that is 1-millimeter thick. ERCP is performed and a normal appearing ampulla is identified. After selective biliary wire access is obtained, a biliary sphincterotomy is performed to allow for therapeutic intervention. An occlusion balloon cholangogram from the common hepatic duct demonstrated filling of the right liver but no significant filling of the left liver, including of the biloma. Despite using multiple types of wires and devices, including passing the sharp end of a wire, we could not access the biloma or the obstructed left hepatic ducts. Injection of contrast via the percutaneous drain defined dilated left hepatic ducts and the biloma, but wire access was still not possible. As such, we decided to use single-operator cholangioscopy to try and selectively access the left liver. The extrahepatic bile duct was unremarkable. ERCP was able to access the left main hepatic duct to its terminus, where a larger closed-off ostium and a smaller inflamed stenotic hole was identified. A 0.025-inch guide wire could not be passed deeply into the stenotic orifice, and this led to oozing of blood. The decision was made to use a holmium YAG laser to recanalize the obstructed bile ducts and biloma. A laser fiber was passed through the cholangioscope. Using cholangioscopy and multiplanar fluoroscopy, we aligned the cholangioscope and laser fiber with the obstructed bile ducts, and the soft tissue distance was reduced to 3 to 4 millimeters. This resulted in the aiming beam and laser fiber being directed at the closed-off ostium. Using a power of 20 watts and 35 pulses, 0.07 kilojoules of energy was delivered to cavitate entry into the obstructed bile ducts in the region of the biloma. A clear passageway into the upstream obstructed ducts was visualized. Despite successful recanalization, the cholangioscope could not be driven through the tunnel. A wire was then able to be passed into the biloma cavity, which was used to facilitate rendezvous capture by the radiologist using a snare passed through the percutaneous tract. Dilation of the PTBD tube was then successful, which led to resolution of her high-output biliary drainage. The patient has since undergone two more ERCPs with removal of her PDBD tube, subsequent dilation of the left hepatic duct stricture, and upsizing of stents draining her left hepatic ducts. Clinical Implications ERCP, cholangioscopy, and fluoroscopic triangulization were combined to target the optimal area to recanalize the left hepatic duct. A short burst of laser therapy was effective at disrupting 3 to 4 millimeters of obstructing tissue without any hemorrhage or perforation. The fluid medium in the biliary tree during this procedure mitigated widespread thermal damage that could result from extended laser pulses. While rarely used in GI endoscopy for recanalization of complete biliary obstruction, Holmium YAG lasers have FDA pre-marketing approval for endoscopic vaporization of soft tissue. As with other endoscopic interventions, informed consent about the risks and benefits is paramount. Other alternative endoscopic salvage strategies could have been pursued. In conclusion, ERCP with cholangioscopy and laser therapy was successful at safely recanalizing a completely obstructed bile duct in this patient with decompensated cirrhosis. This enabled a rendezvous procedure and eventual total internal endoscopic biliary drainage in a patient with post-ablation biloma and symptomatic high-output external drainage.

Liver cirrhosis

Biliary obstruction

Cholangioscopy

Holmium YAG laser

Complete biliary obstruction