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SPYGLASS CHOLANGIOSCOPY IN THE EVALUATION OF AN INTRA‐HEPATIC BILIARY LESION

An 86-year-old man presented with anemia and normal upper and lower gastrointestinal endoscopy. Hemobilia and a bile duct filling defect was noted at endoscopic retrograde cholangiopancreatography but there were no stones. His CA19-9 was elevated at 144 (normal <39). Liver function tests and coagulation profile were normal. Computed tomography and magnetic resonance cholangiopancreatography demonstrated a right anterior intra-hepatic duct (IHD) dilatation with a filling defect. Cholangioscopy with SpyGlass (Boston Scientific, Natick, MA, USA) demonstrated an extensive mucin secreting villous growth in the right IHD, whereas the rest of the biliary tree was normal (Figs 1,2). SpyBite (Boston Scientific) biopsies from the right IHD showed biliary papilloma with lowgrade dysplasia. The patient underwent a right hepatectomy, excision of the extrahepatic biliary tree with Roux-en-Y hepaticojejunostomy. Histology confirmed multiple biliary papillary adenomas with no evidence of malignancy. Biliary papillomatosis is multiple papillary or villous tumors affecting the intra and/or extrahepatic bile duct. It usually presents with cholangitis and imaging showing a dilated biliary tract with a ductal filling defect. Surgical planning requires the nature, site and extent of the disease to be defined. Currently, these lesions are diagnosed by percutaneous or endoscopic video cholangioscopy. However, the percutaneous approach can be complicated by pneumothorax, bile leakage, sepsis and hemobilia and has a 1.7% mortality rate. Limited maneuverability and scope fragility are additional problems with video cholangioscopy. The SpyGlass® direct visualization system is a catheter based mini-endoscope with four-way steering capabilities. It has been reported that the image quality of the SpyGlass fiberoptic probe is inferior to that of the recently introduced electronic video cholangiopancreatoscopes but SpyGlass and SpyBite offer larger tissue biopsies, hence a potentially higher diagnostic yield. In the case described, SpyGlass endoscopy confirmed the nature, site and extent of the disease guiding a curative surgical procedure.