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CC BY 4.0 · Endoscopy 2024; 56(S 01): E724-E725
DOI: 10.1055/a-2375-0187
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Percutaneous transhepatic cholangioscopy combined with endoscopic retrograde cholangiopancreatography for bilateral biliary bridge drainage for malignant biliary obstruction

Gang Tang
1   Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital of Sichuan University, Chengdu, China (Ringgold ID: RIN34753)
,
Jingyi Zhang
2   Department of Medical Ultrasound, West China Hospital of Sichuan University, Chengdu, China (Ringgold ID: RIN34753)
,
Rui Chen
1   Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital of Sichuan University, Chengdu, China (Ringgold ID: RIN34753)
,
Jie Zhang
1   Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital of Sichuan University, Chengdu, China (Ringgold ID: RIN34753)
,
Rongxing Zhou 
1   Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital of Sichuan University, Chengdu, China (Ringgold ID: RIN34753)
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Biliary drainage in advanced malignant hilar biliary obstruction (MHBO) is challenging, especially with Bismuth-Corlette III–IV [1]. By placing a bridge stent between the left and right hepatic ducts, the non-communication system in MHBO can be drained, which is potentially a very promising biliary drainage strategy for MHBO [2]. However, due to the complexity of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) technology, reports on EUS-HGS bridge drainage are still limited. We report a novel approach to bridge bilateral hepatic duct drainage using ultrasound-guided percutaneous transhepatic cholangioscopy (PTCS) combined with endoscopic retrograde cholangiopancreatography (ERCP) in MHBO.

A 57-year-old female with gallbladder cancer presented with jaundice. Computed tomography showed advanced gallbladder cancer with multiple lymph node metastases, hilar bile duct invasion, and biliary obstruction; radical surgery was not possible ([Fig. 1]). Due to the failure of ERCP, we decided after multidisciplinary discussion to combine ERCP with PTCS for palliative bridging biliary drainage. First, the right hepatic duct was punctured under ultrasound guidance. Then, we dilated the occluded common bile duct with a guidewire and balloon and placed a metal biliary stent. Next, we punctured the left hepatic duct through the right hepatic duct with a puncture instrument under ultrasound guidance, expanded the channel with a balloon, and placed a metal biliary stent to bridge the left and right hepatic ducts. Intraoperative X-ray examination with contrast agent injected through the sinus showed good development of both hepatic ducts, indicating successful bridging, but poor imaging of the distal common bile duct suggested that the distal common bile duct may still be slightly narrow ([Fig. 2]). Finally, a 10-Fr plastic stent was placed at the distal common bile duct by ERCP ([Video 1]).

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Fig. 1 Computed tomography showed advanced gallbladder cancer with multiple lymph node metastases, hilar bile duct invasion, biliary obstruction, and bilateral intrahepatic bile duct dilation. a–b The dilated right and left intrahepatic bile ducts. c–d Gallbladder cancer with hilar bile duct invasion.
Zoom Image
Fig. 2 X-ray examination with contrast agent injected through the sinus. a The common bile duct before guidewire puncture and balloon dilation. b After placing a 10 × 60-mm metal stent for the common bile duct. c The left and right intrahepatic bile ducts were bridged with a metal stent (8 × 60 mm); poor imaging of the distal common bile duct.
We successfully performed biliary drainage of the bilateral hepatic duct system using a bridging method from the ultrasound-guided percutaneous transhepatic cholangioscopy combined with endoscopic retrograde cholangiopancreatography in malignant hilar biliary obstruction.Video 1

The jaundice disappeared a few days after surgery. Ultrasound-guided PTCS combined with ERCP for bridging drainage of bilateral hepatic ducts is a feasible treatment option for MHBO.

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Publication History

Article published online:
08 August 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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  • References

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