Cholangioscopy-guided laser ablation for intraductal papillary neoplasm of bile duct

A 65-year-old man with a history of metastatic bladder cancer was admitted with jaundice. Blood tests revealed a cholestatic pattern of liver function, hyperbilirubinemia, and deranged clotting profile. Computed tomography and magnetic resonance cholangiopancreatography showed cirrhosis and dilated extrahepatic and intrahepatic biliary systems without hyperdense stones ([Fig. 1]). Endoscopic retrograde cholangiopancreatography revealed a fish-mouth deformity of the papillary opening ([Fig. 2]), dilated intrahepatic ducts, and poor contrast filling of the common bile duct ([Fig. 3]). Repeated balloon trawling (18 mm) yielded a copious amount of jelly-like mucus. Cholangioscopy (SpyGlass; Boston Scientific, Natick, Massachusetts, United States) revealed multiple foci of papillary growth in the upper common bile duct, common hepatic duct, and proximal left biliary duct ([Fig. 4]). The biopsy samples revealed papillary proliferation with a gastric subtype and low-grade dysplasia. A diagnosis of intraductal papillary neoplasm of the bile duct (IPNB) was made. Repeat cholangioscopy was performed by introducing an end-on irradiation fiber connected to a laser system (Leonardo 1470 nm/980 nm dual-wavelength laser; CeramOptec GmbH/Biolitec AG, Bonn, Germany) ([Fig. 5]). Ablation of the papillary growth was performed until a whitish discoloration and necrosis appeared ([Video 1]). The patient did not experience any discomfort or adverse events after the procedure and was discharged 9 days later.

Fig. 1 Magnetic resonance cholangiopancreatography revealing dilated extrahepatic and intrahepatic biliary systems.

Fig. 2 Endoscopic image of fish-mouth deformity of the papilla.

Fig. 3 Endoscopic retrograde cholangiopancreatoscopy revealing filling defects due to mucus.

Fig. 4 Cholangioscopic image revealing papillary growths.

Fig. 5 Application of cholangioscopy-guided laser on the papillary growth.

Cholangioscopy-guided laser ablation of intraductal papillary mucinous neoplasm.Video 1

IPNB is an epithelial tumor characterized by intraductal papillary proliferation and a thin fibrovascular stem on histological analysis [1]. Due to the risk of progression to cancer, surgical resection is recommended. However, surgery was contraindicated for our patient. Furthermore, the insertion of a biliary stent does not relieve biliary obstruction due to the viscous nature of the mucus. The use of cholangioscopy-guided laser to dissect benign biliopancreatic ductal strictures [2] [3] and for ablation of cholangiocarcinoma [4] has been reported previously. Our experience suggests that laser has good ablative effects and may be a promising treatment modality for IPNB, particularly for patients who are unfit for surgery.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Sakai Y, Ohtsuka M, Sugiyama H. et al. Current status of diagnosis and therapy for intraductal papillary neoplasm of the bile duct. World J Gastroenterol 2021; 27: 1569-1577
• 2 Mittal C, Shah RJ. Pancreatoscopy-guided laser dissection and ablation for treatment of benign and neoplastic pancreatic disorders: an initial report (with videos). Gastrointest Endosc 2019; 89: 384-389
• 3 Han S, Shah RJ. Cholangiopancreatoscopy-guided laser dissection and ablation for pancreas and biliary strictures and neoplasia. Endosc Int Open 2020; 8: E1091-E1096
• 4 Xia M, Hu X, Zhang T. et al. Laser ablation under intraductal cholangioscopic guidance for cholangiocarcinoma. Endoscopy 2023; 55: E590-E591

Publication History

Article published online:
26 July 2024