ENDOSCOPIC MANAGEMENT OF DIFFICULT BENIGN BILIARY AND PANCREATIC STRICTURES USING A WIRE-GUIDED CYSTOTOME

Aim:

Endoscopic management using standard accessories is the preferred modality for treating benign biliary/pancreatic strictures. However, if there're difficult and severe strictures, the passage of accessories over a guidewire across the stricture isn't feasible. Hence, our aim is to report our experience regarding the use of a standard diathermic dilator (cystotome) to aid in stricture dilation and stent placement in patients with difficult strictures.

Methods:

We report 4 patients with biliary/pancreatic severe strictures treated with a 6-Fr cystotome with diathermic metal tip (CystoGastro-set; Endoflex, Germany). In all cases the cystotome was passed over the guidewire under fluoroscopic guidance and the current was applied until the tip of the cystotome crossed the stricture. Efficacy of stricture dilation was considered when stent placement was achieved with adequate ductal drainage after standard endoscopic therapy failure; safety was considered the absence of complications during 30-day follow-up.

Results:

In 1 patient with liver transplant (LT) and 1 patient with prior cholecystectomy, a guidewire was passed across the stricture using SpyGlassDS; however, biliary balloon catheter couldn't pass across the stricture so a wire-guided 6Fr-cystotome was used.

In another patient with LT, a guidewire was passed across the papilla by EUS-assisted biliary rendezvous technique. Then, a 6Fr-cystotome was usedafter a biliary balloon catheter couldn't pass.

About pancreatic stricture in a patient with chronic pancreatitis, retrograde cannulation failed, hence EUS-assisted pancreatic rendezvous technique was performed. Once the guidewire passed across the papilla, a pancreatic balloon dilator couldn't pass across the stricture. Then, a wire-guided 6Fr-cystotome was successfully used.

In all cases, after using 6Fr-cystotome, stent placement and duct drainage were successfully achieved; there weren't complications during follow-up.

Conclussion:

The cystotome can be an effective and safety tool in the management of difficult benign biliary and pancreatic strictures, whereas conventional methods to negotiate stricture have failed.