ENDOLUMINAL RADIOFRECUENCY ABLATION WTH SPYGLASS IN THE MANAGEMENT OF CHOLANGIOCARCINOMA

Male patient of 38 years. Medical history: ambulatory clinical follow-up due to cryptogenic liver cirrhosis. Admitted in April 2018 for spontaneous bacterial peritonitis (SBP). During abdominal MRI admission, a lesion was reported in the hepatic hilum with hilar adenopathies compatible with cholangiocarcinoma. Due to marked portal hypertension and poor clinical improvement, a TIPS was placed 2 months after admission without clinical changes. On July 18, ERCP with SpyGlass was applied, biliary stents placement with biliary biopsy of suspicious lesion was taken. We took only one sample due easy bleeding. Pathology report: suspicious but not conclusive with cholangiocarcinoma. After that, the patient presented remarkable clinical improvement. PET-CT was performed to confirm malignant diagnosis, reporting hilar cholangiocarcinoma with tumor viability signs, with intrahepatic bile ducts dilation. Sepsis concurrent SBP and antibiotic therapy was initiated with multiple antibiotic schemes by multiresistant bacterias for 2 months. Endocarditis and other endovascular infections were ruled out. Four months after admission, oncology committee requested to repeat biliary biopsies and get adenopathies biopsy. Endoscopic ultrasound with FNA in August 2018 confirmed metastatic lymphadenopathies. In September 2018, second ERCP with SpyGlass system was performed; Endoscopic biopsy by SpyBite confirmed cholangiocarcinoma. With these findings, the patient did not meet Mayo Clinic criteria for curative resection, so endoluminal radiofrequency with Spyglass was offered as palliative treatment. An 18 mm temperature-controlled radiofrequency (RFA) catheter (ELRA STARmed, Korea) through duodenoscope working channel into the papilla of Vater was inserted. RFA was applied at 10 watts for a time period of 2 minutes under 80 °C of intraductal temperature. A temperature sensor inside the electrode provided accurate temperature measurements. The power and impedance settings were automatically made from the VIVA generator (STARmed Korea). After the procedure, patient presented mild self-limited abdominal pain for 12 hours, with no other complications 15 days after the procedure.