Clangioscopy guided double guide wire technique for the management of complex malignant hydra obstruction presented by Margaret Keane. These are our disclosures. In clangiocarcinoma, successful biliary drainage with normalisation of bilirubin is associated with improved survival. Selective intrapathic ductal cannulation during ERCP can be challenging, especially in high restriction. In this case, a 77-year-old man presented to our institution with jaundiced right upper quadrant pain, loss of appetite and weight loss. Blood tests confirmed a raised bilirubin of normal liver function tests and a significantly elevated CO19. Cross-sectional imaging by MRI showed multiple liver metastasis with a higher mass and intrapathic biliary dilatation. Recognising the patient probably had metastatic clangiocarcinoma but would not be a liver transplant candidate because of disseminated disease, we proceeded to EUS and ERCP. Linear EUS was performed from the first part of the duodenum and showed thickening of the distal CBD. On talking the echoendoscope towards the hilum, a 2cm mass came into view. An FNA was performed with a 25-gauge needle and two passes were obtained. At ERCP, selective biliary cannulation was achieved with a sphinctrotone preloaded with an O2-5 wire, but deep biliary cannulation could not be achieved. To better visualise the obstructing lesion, a single-operated phalangioscope was then advanced over the wire into the extraphatic bile duct. Below the hilum there was an infiltrative hilum mass with nodular, flyable mucosa and torturous vessels, highly suggestive of clangiocarcinoma. Endoscopic biopsies under direct visualisation by phalangioscopy were obtained. In clangiocarcinoma, phalangioscopy is primarily used for tissue acquisition and defining tumour extent. However, in complex hynostrictures, it also has a recognised role in selective intrapathic biliary cannulation. This patient had a bismuth type 3a stricture, so our aim was to stent the right anterior and right posterior ducts. Initially the wire preferentially went into the left intrapathic ducts and no access to the right intrapathic ducts could be achieved. With repositioning of the phalangioscope below the hilum, two additional ductal openings could be identified within the malignant hilar stricture. Each opening was selectively cannulated in turn and fluoroscopy confirmed they were the origin of the right posterior and the right anterior systems. In complex hilar strictures, following selective intrapathic wire placement, it becomes impossible to reintroduce the phalangioscope via the endoscope working channel to aid placement of a second wire. Not wanting to forgo access to either the right anterior or the right posterior ducts in this case, we attempted to place a second guide wire through the phalangioscope. A second hydrophilic 0.025 inch guide wire was advanced alongside the first wire. Using phalangioscopy, the origin of the right posterior duct could be visualised to enable selective segmental wire placement. Here both guide wires can be seen side by side and across the stricture. Despite two 0.025 inch guide wires measuring a total of 1.27 mm in diameter, these hydrophilic wires pass relatively easily via the 1.2 mm therapeutic channel of the phalangioscope. The phalangioscope was then exchanged with the two wires remaining in situ. A dilating balloon was advanced over each wire in turn and the strictures sequentially balloon dilated. Two 7 French 12 cm straight plastic fillery stents were then placed into the right anterior and right posterior ducts. The stents were in a good position at the end of the procedure, draining contrast and oil. Cytology from EUSFNA was ultimately non-diagnostic, but phalangioscopy-directed biopsies confirmed adenocarcinoma. After placement of bilateral stents into the right anterior and right posterior ducts, the bilirubin normalised. Palliative chemotherapy was then commenced with gemcitabine and cisplatin. In conclusion, in hyalocalangiocarcinoma, in addition to tissue acquisition and staging, phalangioscopy can aid selective intrapathic biliary cannulation. This case outlines a new novel technique called phalangioscopy-guided double guide wire placement for complex hyalostrictures. Thank you for watching. For more information, visit www.fema.gov

Clangioscopy

double guide wire technique

complex malignant hydra obstruction

biliary obstruction

clangiocarcinoma