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Peroral cholangioscopy via an endoscopic ultrasound-guided hepaticojejunostomy route for distal bile duct cancer with Roux-en-Y reconstruction
A 70-year-old man who had undergone total gastrectomy with Roux-en-Y reconstruction was referred to our hospital with liver dysfunction. Imaging studies revealed a distal biliary stricture with dilated intrahepatic bile ducts ([Fig. 1]), indicating possible distal cholangiocarcinoma. In order to perform peroral cholangioscopy to determine malignancy and extent of superficial spread, we planned to construct an endoscopic ultrasound-guided hepaticojejunostomy (EUS-HJS) route.
The dilated intrahepatic bile duct (B3) was punctured via the jejunum under EUS guidance using a 19-gauge needle (Expect; Boston Scientific Corp., Marlborough, Massachusetts, USA). An 8 mm/8 cm fully covered self-expandable metallic stent (FCSEMS; HANAROSTENT biliary; MI Tech, Gyeonggi-Do, Korea) was then deployed across the EUS-HJS route after dilating it with a 7-Fr dilator ([Fig. 2]). After improvement in liver function, peroral cholangioscopy via the FCSEMS was carried out using the SpyGlass DS system (Boston Scientific Corp.) ([Video 1]). Under cholangioscopic guidance, papillary mucosa with irregular vessels was mainly detected in the distal bile duct but not in the hilar and intrahepatic bile ducts ([Fig. 3], [Fig. 4], [Fig. 5]). In addition, we performed mapping biopsies using SpyBite forceps (Boston Scientific Corp.) in the distal, hilar, and intrahepatic bile ducts.
Video 1 Construction of an endoscopic ultrasound-guided hepaticojejunostomy route and subsequent peroral cholangioscopy for the determination of malignancy and extent of superficial spread.
As adenocarcinomas were found only in the distal bile duct, the patient was scheduled to undergo pancreaticoduodenectomy. Histological findings of the resected specimens indicated that cholangiocarcinomas were located in the distal bile and cystic ducts. The FCSEMS deployed in the EUS-HJS route was endoscopically removed 30 days after surgery.
Although peroral cholangioscopy for patients with possible distal cholangiocarcinoma is effective for determination of malignancy and extent of superficial spread , the transpapillary approach is challenging to perform in patients with altered anatomies. Therefore, peroral cholangioscopy via an EUS-guided bilioenterostomy route  may be a useful alternative to the transpapillary approach for evaluating possible distal cholangiocarcinomas.
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12 May 2021 (online)
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- 1 Ogawa T, Ito K, Koshita S. et al. Usefulness of cholangioscopic-guided mapping biopsy using SpyGlass DS for preoperative evaluation of extrahepatic cholangiocarcinoma: a pilot study. Endosc Int Open 2018; 06: E199-E204
- 2 Mukai S, Tsuchiya T, Itoi T. et al. Endoscopic ultrasonography-guided hepaticogastrostomy with novel two-step puncture technique following peroral cholangioscopy-assisted stone removal. Dig Endosc 2020; 32: e32-e33