Balloon-catheter-assisted endoscopic snare resection for choledochocele using a single-channel duodenoscope

Choledochocele, or type III choledochal cyst in Todani’s classification, is a rare congenital disease [1] [2] [3]. Pancreatobiliary symptoms and the risk of malignancy are the reasons for treatment, which is usually done by surgical excision or, in some cases, by endoscopic resection [2] [3] [4] [5].

A 75-year-old man with abdominal pain, jaundice, occasional fever, elevated canalicular enzymes, conjugated bilirubin (1.3 mg/dL, normal range 0.1 – 0.4 mg/dL) and cholelithiasis, and choledocholithiasis with common bile duct dilatation as seen on ultrasonography and CT scan, underwent endoscopic retrograde cholangiopancreatography (ERCP), which also revealed a choledochocele ([Fig. 1]). The patient refused surgery and a balloon-catheter-assisted endoscopic snare resection with a single-channel therapeutic duodenoscope was performed.

Fig. 1 Endoscopic retrograde cholangiopancreatography showing the choledochocele.

After catheterization of the common bile duct with a guide wire, a balloon catheter was passed through the loop of a 20-mm-diameter snare which wrapped around the wire and was then inserted deeply into the choledochocele ([Fig. 2]). The insufflated balloon was pulled back toward the duodenal lumen and the snare grasped close to the base of the choledochocele, and the marsupialization was completed ([Fig. 3]). After this, sphincterotomy was performed and stones removed.

Fig. 2 Snare wrapped around the balloon to fit in a single-channel duodenoscope.

Fig. 3 Balloon-catheter-assisted endoscopy snare resection technique: schematic diagram and endoscopic image.

The cyst had duodenal mucosa externally and choledochal mucosa internally with no atypical changes. A laparoscopic cholecystectomy was done and the patient remains without symptoms and with normal findings on endoscopic follow-up after 1 year ([Fig. 4]).

Fig. 4 Follow-up 1 year after endoscopic resection.

The risk of biliary duct perforation during surgical resection is well known; however, because endoscopic resection is a new method, the risk it presents is as yet unknown; more studies are needed on this subject. The technique employed here has been described before using a double-channel duodenoscope, and this is easier because it is not necessary to manage the accessories outside of the duodenoscope before introducing the whole system into the channel [5]. However, since a double-channel duodenoscope is not available in all hospitals, the present case report shows that the single-channel technique can be performed with the same results and is also an innovative and minimally invasive technique for the treatment of symptomatic choledochocele.

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References

• 1 Singham J, Yoshida E M, Scudamore C H. Choledochal cysts. Part 1 of 3: Classification and pathogenesis.  Can J Surg. 2009;  52 434-440
• 2 Chatila R, Andersen D K, Topazian M. Endoscopic resection of a choledochocele.  Gastrointest Endosc. 1999;  50 578-580
• 3 Berger A, Douard R, Landi B. et al . Endoscopic management of a large choledochocele associated with choledocholithiasis.  Gastroenterol Clin Biol. 2007;  31 200-203
• 4 Singham J, Yoshida E M, Scudamore C H. Choledochal cysts. Part 3 of 3: Management.  Can J Surg. 2010;  53 51-56
• 5 Itoi T, Gotoda T, Yasuda I. et al . Balloon-catheter-assisted complete endoscopic snare resection for choledochocele by using double-channel duodenoscope (with videos).  Gastrointest Endosc. 2007;  66 622-625