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Transcutaneous SpyGlass-guided rendezvous

Dr. Christian Dietrich, Dr. Erik-Sebastian Fuchs, Prof. Dr. Ralf Jakobs, Dr. Christian Dietrich

Medizinische Klinik C - Klinikum der Stadt Ludwigshafen

Introduction and case report

Achieving sustained biliary drainage in patients with cholestasis or cholangitis often represents a turning-point in the treatment of malignant and infectious diseases with hepatobiliary involvement. In this case — a 76-year-old woman with carcinoma of the pancreatic head, with hepatic metastases — endoscopic retrograde access was not possible, due to tumor tissue extending as far as the hepatic portal. Alternative procedures include percutaneous transhepatic cholangiography and drainage (PTCD) or endoscopic ultrasound–guided drainage techniques, with the advantages and disadvantages associated with each [1]. (For further information on this, reference may be made to the video contribution by B. Walter and A. Meining from Ulm in Endoscopy Campus [2]).

Transcutaneous bile drainage is possible after PTCD, but it is associated with a complication-prone loss of fluid and electrolytes and is susceptible to stent dislocation. For longer-term treatment, the aim must be to internalize the drainage from a transcutaneous to an intestinal route. This was not achieved in the present case even after the use of different catheters and various wires for guidance. In the following illustrations, we present an advanced technique with transcutaneous SpyGlass DS II–guided biliary drainage using a rendezvous technique, ending with successful placement of a metal stent. In this case, the procedure enabled the patient to undergo outpatient chemotherapy.

A special percutaneous version of the SpyGlass has recently been presented. In the present case, the regular SpyGlass DS II was used — with the advantage over conventional cholangioscopes that it only requires a small biliocutaneous tract diameter (12 versus 14–18 Fr).


Fig. 1: The initial situation on the upper abdominal CT (portal venous phase). Green = common hepatic duct (CHD); blue = pancreatic duct. Carcinoma of the pancreatic head (arrow) and a large juxtapapillary diverticulum are preventing endoscopic retrograde access to the bile duct. A favorable transduodenal access route was not identified on endoscopic ultrasound.

Fig. 2: Transcutaneous cholangiogram. The dilated bile duct system, with occlusion in the middle of the common bile duct. There is no contrast at all draining through the stenosis into the duodenum. It was not possible to pass a percutaneous wire under fluoroscopic guidance. Bougienage of the tract to 13 Fr initially was achieved in two sessions, and it was temporarily secured with a 12-Fr biliary drainage catheter (Cook).
Fig. 3: The SpyGlass DS II© is advanced transcutaneously as far as the tumor stenosis, and a long Jagwire (450 cm, 0.035 inches) is advanced with cholangioscopic visualization. The arrow marks the diverticulum seen on the CT.

Fig. 4: A rare duodenoscopic view of the papilla: rendezvous with the transcutaneously introduced SpyGlass©. Using grasping forceps, the transcutaneous wire is led out orally through the working channel of the duodenoscope. Using the classic technique, the metal stent is then implanted over the transcutaneous–transendoscopic wire via the working channel.
Fig. 5: Radiograph of the self-expanding metal stent (SEMS, 10 × 60 mm) introduced via the duodenoscope . The transcutaneous angiocatheter that is still in place here can be removed afterward. The transcutaneous tract then quickly closes.

References

  1. Duan F, Cui L, Bai Y et al. Comparison of efficacy and complications of endoscopic and percutaneous biliary drainage in malignant obstructive jaundice: a systematic review and meta-analysis. Cancer Imaging. 2017 Oct 16;17(1):27. doi: 10.1186/s40644-017-0129-1.

2. Walter B, Meining A. Transgastric biliary drainage with metastatic gallbladder cancer [video, Internet]. Munich: Endoscopy Campus GmbH; 2016 Nov 12. Available at: https://www.endoscopy-campus.com/en/lehrvideo/transgastric-biliary-drainage-with-metastatic-gallbladder-cancer/. Accessed 2021 Jun 29.

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