Here's a 54-year-old woman with adrenal cortical carcinoma that's metastatic to the hilum. She's got a large liver metastasis. She had good performance status and quality of life until the onset of jaundice. Now she's got intractable pruritus from that jaundice. She also can't get her chemotherapy unless her belly gets below two. So the oncologists have asked for a biliary stent placement. So here's a few months ago, November 2020, an MR. You can see the size of that mass, and she already had left ductal dilatation at that point. You can see, though, that the left system looked quite confluent, which means you can probably get one stent in there and drain the whole thing. By last month, you can see the tumor mass is much larger, but there's still a fairly big confluent drainage field in the left. You don't see much dilated in the right other than what's near the tumor, which is a no-no. And then this right posterior system, which doesn't look as hugely confluent. So here's a papilla. That looks normal. We get in with a papillotome, perform a sphincterotomy. And here's a little bit of video. I first tried a 0.35-inch hydrophilic angled guide wire, but that guide wire was even too thick. These adrenal cortical carcinomas are extremely hard cancers, hard substance cancers. So I switched out to the 0.018-inch guide wire. It has a little gold tip on it because the wire itself isn't very radiopaque. It's kind of hard to see. I've inflated an 8.5-millimeter balloon on this occlusion balloon catheter in order to use it as a fulcrum to sort of be able to rock the tip of the catheter, which is right here, back and forth to try, as I spin and dart this guide wire, loop and unloop it, to crawl up that left duct that I wanted to get into. And I know from the images that this is a confluent system. So now I've gotten the wire way out to the periphery of that left duct. I'm happy with that. And what I'm going to do, this is a 4.6 to 6 French passage tapered catheter dilator. And I am putting this up there not just to dilate the stricture, but I'm putting it up there because this is one of the few devices that will go well over an 0.018 guide wire, but will also take an 0.035 guide wire. So if I can get this dilator up over that wire, I can pull that skinny wire out and put my thicker wire back in and do my work with a more radiopaque guide wire. So here you go. Here's the 0.035 wire. And I don't want the stent to have to take that kind of a crazy turn, cephalad. And so I will spin this wire and loop it and such, ultimately, in order to get it back in the same lateral duct on the left there that I had gotten that initial wire in. And there we have it looped. So you see how big the duct is way out there. So then we're going to, so we've got an 0.035 wire up there. I know it's looped in a nice big duct. So I'm going to put a catheter up there and start injecting it. And you will see that this is a confluent system. I'm going to speed it up a bit. You can see this. That's what it looks like. So then ultimately, we will balloon dilate this stricture. And I think you can see the balloon going up there. And you can see how tight that waste is there. And we do a few serial inflations to get this thing dilated. And then there goes our stent. And you can see we're having quite a struggle down here pushing that stent across that stricture, because even after a balloon dilation, man, that is tight. But look, all these left ducts are confluent. They're all going to drain, particularly with this stent, because it has multiple side holes in it. And as you're going to see here, that's what it looks like when we're done. I'm sizing this up by putting the balloon catheter beside it and the skinny wire to see if it's even possible to get a second stent in there. And I can see that even the skinny wire just loops out. And I absolutely can't get a catheter up there. So that is the drainage that we got. And this lady's jaundice actually went away with that. And that is the drainage that we got.

metastatic adrenal cortical carcinoma

jaundice

intractable pruritus

biliary stent placement

duct dilation