ENDOSCOPIC REMOVAL OF TUBULOVILLOUS ADENOMA WITH HIGH-GRADE FOCAL DYSPLASIA IN THE DISTAL COMMON BILE DUCT

Introduction:

A pluripathology 80-year-old female was admitted for cholangitis. A dilatation of the common bile duct (CBD) and a possible distal choledocholithiasis was shown in CT scan. An ERCP was performed and the duct was swept with a balloon, showing a polypoid lesion of adenomatous appearance through the papilla. The pathology confirmed a tubulo-villous adenoma with high-grade focal dysplasia. An EUS revealed the presence of a polyp of 10 × 8 mm in the CBD. In accordance with a multidisciplinary committee and being a high risk surgical patient, an endoscopic treatment was indicated.

Description of the technique:

The papilla is achieved with the duodenoscope and a papilloplasty is performed with a 12 mm pneumatic balloon. With the help of the Fogarty balloon and a biopsy forcep, the polyp is tractioned towards the duodenum and then the polypectomy is done with a pediatric hot snare. Later, a fulguration with soft coagulation is done and a fully covered self-expanding metallic biliary stent is placed. Follow-up at 2 months, no macroscopic lesion is observed with a baby scope cholangioscopy, after removing the stent. In addition, fulguration with Argon-Beam (30W) is applied in the site of polypectomy. In next follow-up at 6 months no remains of polyp is seen with a baby scope cholangioscopy. Pathology confirmed the absence of adenoma at 2 and 6 months. No complications detected during the follow-up.

Conclusions:

Adenomas of the extrahepatic bile duct are uncommon benign neoplasms with an unknown malignant potential. Surgery is the current treatment, and there are only 5 published cases of endoscopic treatment, with good results in non-surgical patients. In our case, the keys to achieve a technical success were to have a good visualization through the papilla (papilloplasty + stent) and the use of a pediatric polypectomy snare with the help of the balloon.