A 65 years old Male
Presented with severe obstructive jaundice (Total bilirubin – 21mg %) associated with fever and chills
CT scan suggestive of a right lobe of liver mass
EUS – Stricturous lesion at the CHD leading to massively dilated right and left hepatic ducts and IHBR dilatation
Deep cannulation of the stricturous area of the CBD could not be achieved endoscopically.
Therefore PTC guided internalization was attempted which was not successful and a 8.5 Fr external drainage catheter was placed for biliary decompression
Repeat attempt of internalization was done after 3 days and guidewire could be negotiated across the stricture but the catheter could not be negotiated across.
In view of these findings PTC rendezvous with parallel cannulation alongside the drain was attempted with a sphincterotome cannula. After successful cannulation, the drain was progressively withdrawn, allowing retrograde therapeutic intervention.
ERC revealed hilar stricture with dilated right and left hepatic duct and the distal CBD appeared dilated suggestive of a cholangiocarcinome in a setting of choledochal cyst.
Biliary brushing confirmed it to be a cholangiocarcinoma. A 10 cm self expandable metallic biliary stent was placed in the right hepatic duct. Free flow of bile seen from the placed stent.
Choledochal cyst complicated to cholangiocarcinoma in approximately 26 %.
PTC Rendezvous with Parallel cannulation is straightforward and effective, especially in cases of long standing cholestasis leading to edema at the stricturous site preventing antegrade cannulation.
Hilar strictures are challenge for stenting as infectious complications make the stricture more edematous and difficult to cannulate.
A complete Sphincterotomy with multiple stenting is necessary for adequate drainage of the bile, thus necessitating the need for endoscopic approach as compared to the PTC internalization
Take Home Message:
As hilar strictures are more for infectious complications. Therefore biliary decompression by temporary external drainage is necessary to facilitate subsequent intervention.
Cholangiocarcinoma complicating the choledochal cyst presents at an advanced stage as compared to the denovo cholangiocarcinoma, as in this case at the presentation patient had wide spread hepatic involvement.
PTC guided External drainage with a 8.5 Fr Catheter
PTC rendezvous with Parallel cannulation of CBD across the stricture
ERC showing hilar stricture with Type I choledochal cyst
Self expandable metallic biliary stent in situ
Fluoroscopy showing Self expandable metallic biliary stent in situ