Novel technique for intraductal cholangioscopy-assisted biliary drainage with over-the-wire microcatheter manipulation

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

Competing interests

None

• References

• 1 Barkay O, Bucksot L, Sherman S. Endoscopic transpapillary gallbladder drainage with the SpyGlass cholangiopancreatoscopy system. Gastrointest Endosc 2009; 70: 1039-1040
• 2 Shin JU, Lee JK, Kim KM. et al. Endoscopic naso-gallbladder drainage by using cholangioscopy for acute cholecystitis combined with cholangitis or choledocholithiasis (with video). Gastrointest Endosc 2012; 76: 1052-1055
• 3 Bokemeyer A, Gross D, Bruckner M. et al. Digital single-operator cholangioscopy: a useful tool for selective guidewire placements across complex biliary strictures. Surg Endosc 2018; DOI: 10.1007/s00464-018-6334-6.
• 4 Tyberg A, Zerbo S, Kahaleh M. et al. Digital cholangioscopy-assisted gallbladder drainage: seeing is accessing. Endoscopy 2015; 47 (Suppl. 01) E417
• 5 Yoshida M, Morimoto M, Kato A. et al. Recanalization of postoperative biliary disconnection with intraductal cholangioscopy-assisted forceps retrieval of rendezvous guidewire. Endoscopy 2018; 50: E338-E339