Cholangioscopy-assisted guidewire placement is reported to be a useful method for
endoscopic biliary drainage that is made difficult by complex strictures and obstructions
[1]
[2]
[3]
[4]
[5]. However, the guidewire sometimes becomes misdirected because of the lack of contrast-filled
images. With the aim of improving safety and certainty, we present two practical cases
that employ a novel technique using an over-the-wire microcatheter through digital
intraductal cholangioscopy (IDC) (SpyGlass DS; Boston Scientific, Natick, Massachusetts,
USA).
Case 1 involved a 72-year-old woman with hilar cholangiocarcinoma who underwent endoscopic
biliary drainage for segmental cholangitis. The cholangiogram showed complete obstruction
of the left hepatic duct ([Fig. 1]). Although direct visualization with IDC allowed advancing the 0.025-inch guidewire
over the obstructing tumor in the left hepatic duct, the guidewire lost the pathway
to the left intrahepatic bile duct. The 3-Fr outer sheath of a basket catheter (MicroCatch;
MTW Endoskopie, Düsseldorf, Germany), which can be inserted into the SpyGlass DS,
was introduced as a microcatheter in order to inject contrast medium and assist guidewire
manipulation. The contrast-filled image of the left intrahepatic bile duct allowed
successful negotiation ([Fig. 2]), followed by replacement of the endoscopic nasobiliary drainage tube ([Video 1]). Case 2 involved a 79-year-old man with acute cholecystitis. The cholangiogram
showed complete obstruction of the cystic duct ([Fig. 3]), which prevented guidewire advancement under fluoroscopic imaging. The orifice
of the cystic duct was visualized using the SpyGlass DS, then the guidewire with a
3-Fr endoscopic nasobiliary drainage tube (Daimon-PTCD set, Hanaco Medical, Saitama,
Japan), another microcatheter that may be used through the SpyGlass DS, was advanced
into the cystic duct ([Fig. 4]). At one point when the guidewire was advanced in an unknown direction, contrast
injection through the microcatheter showed clearly that the guidewire had penetrated
the peritoneal cavity ([Fig. 5]). The microcatheter also assisted with maneuvering of the guidewire to correct its
course, resulting in successful access to the gallbladder, completed by insertion
of a plastic stent ([Video 1]).
Fig. 1 Case 1: Endoscopic retrograde cholangiography shows complete obstruction with no
flow of contrast into the left intrahepatic bile duct in a patient with hilar cholangiocarcinoma.
Fig. 2 A 3-Fr over-the-wire microcatheter (arrow) introduced via intraductal cholangioscopy
allowed injection of contrast into the target bile duct.
Video 1 Novel technique with over-the-wire microcatheter manipulation for SpyGlass DS-assisted
selective biliary drainage.
Fig. 3 Case 2: Endoscopic retrograde cholangiography does not show the orifice of the cystic
duct, preventing transcystic guidewire advancement under fluoroscopic imaging in a
patient with acute cholecystitis.
Fig. 4 Direct cholangioscopy reveals the orifice of the cystic duct and allows insertion
of the guidewire with the over-the-wire microcatheter.
Fig. 5 Cholangiography on contrast pressure injection via the over-the-wire microcatheter
(arrow) shows the extra cavity from the cystic duct, indicating guidewire penetration
into the peritoneal cavity.
Cholangioscopic operation with a microcatheter offers advantages both for obtaining
selective contrast-filled images and for delicate manipulation of the guidewire as
performed in selective angiographic examinations.
Endoscopy_UCTN_Code_TTT_1AR_2AK
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