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A 64-year-old woman underwent a segment 5/6 liver resection in February 2016 for cholangiocarcinoma. Chemotherapy was poorly tolerated and, therefore, was stopped in August 2016.
She experienced obstructive jaundice in September 2016 with CT confirmation of intrahepatic duct dilation (Fig. 1). ERCP showed a Bismuth type 1 stricture (Fig. 2), and a 10-mm uncovered metal stent (Wallflex; Boston Scientific, Natick, Mass, USA) was inserted. Subsequently, she experienced episodes of recurrent cholangitis from rapid stent occlusion with tissue ingrowth, but biopsies and brushings were negative for malignancy. Further ERCPs were performed to relieve the biliary obstruction, and another uncovered metal stent was placed within the existing metal stent.
She presented again with sepsis in March 2017, and a CT scan revealed a segment 7 liver abscess with an associated undrained liver segment and left-sided intrahepatic duct dilation (Fig. 3). She responded well initially to antibiotics and percutaneous drainage.
Figure 3CT scan showing left-sided intrahepatic duct dilatation and a segment 7 liver abscess.
Subsequently, in June 2017, she underwent an ERCP with Spyglass DS cholangioscopy (Boston Scientific, Natick, Mass, USA) to evaluate the intrahepatic biliary obstruction, to confirm suspected malignant involvement, and to treat this with radiofrequency ablation. ERCP and cholangioscopy showed a malignant-appearing Bismuth IIIa hilar stricture, confirmed on examination of biopsy specimens (Fig. 4; Video 1, available online at www.VideoGIE.org). The various obstructed segments were accessed (Fig. 5). Radiofrequency ablation was performed with the Habib HPB probe (EMcision, Montreal, Canada) to each obstructed segment. The immediate postablation cholangioscopic appearance of the treated tumor confirmed necrotic tissue (Fig. 6). The infected segment 7 was accessed again, and after balloon dilation, large amounts of pus were removed. Biliary drainage to each segment was maintained with three 7F gauge plastic stents.
Figure 4Fluoroscopic image showing Bismuth type IIIa hilar stricture.
Six weeks later, repeated ERCP and cholangioscopy confirmed the efficacy of radiofrequency ablation with no macroscopic evidence of residual intraductal tumor (Fig. 7), making it possible to position three 8-mm self-expanding uncovered metal stents (Zilver; Cook Group, Bloomington, Ind, USA) into the 3 obstructed biliary segments.
Figure 7Cholangioscopic image showing changes 6 weeks after radiofrequency ablation.
The patient responded positively to her treatment, inasmuch as she avoided a hospital stay for a prolonged period of time without further evidence of cholangitis and no adverse events related to the procedure itself. The outcomes for this patient are consistent with the outcomes described in the current literature.
Radiofrequency ablation combined with biliary stent placement versus stent placement alone for malignant biliary strictures: a systematic review and meta-analysis.
Initial cholangioscopic view with use of Spyglass DS system and confirmation of malignant hilar structuring. Radiofrequency ablation was then performed with use of the Habib HPB probe. Repeated immediate and delayed (at 6 weeks) cholangioscopic images showing biliary appearance after radiofrequency ablation.
Reference
Sofi A.A.
Khan M.A.
Das A.
et al.
Radiofrequency ablation combined with biliary stent placement versus stent placement alone for malignant biliary strictures: a systematic review and meta-analysis.
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