Biliary - Peroral Direct Cholangioscopic Argon Plasma Coagulation (APC) by Using an Ultra-slim Upper Endoscope for Recurrent Hepatoma with Intraductal Nodular Tumor Growth
Comments: Hepatocellular carcinoma invading the bile duct frequently presents with obstructive jaundice and cholangitis.
To date, percutaneous cholangioscopic ethanol injection or microwave coagulation therapy is one of the techniques used to control intraluminal tumors.
However, a percutaneous approach may require sinus tract maturation, resulting in delayed management and developing procedure-related complications.
The peroral approach appears safer and faster than percutaneous cholangioscopy, however, peroral cholangioscopy has remained a very cumbersome and time-consuming procedure due to a "mother-baby endoscopic system".
Recently, a feasibility study on an ultra-slim upper endoscope for peroral direct cholangioscopy (PDCS) without a “mother-baby endoscopic system” was reported.1
However, the therapeutic role of this type of endoscope for bile duct lesions is uncertain.
We describe the first therapeutic report of peroral direct cholangioscopic argon plasma coagulation (APC) with an ultra-slim upper endoscope for recurrent hepatoma with intraductal nodular tumor growth.
A 67 year-old woman was admitted for intermittent epigastric pain and obstructive jaundice for five days' duration. Six months previously she had undergone wedge resection of segment eight because of hepatoma.
A CT showed right intra- and extrahepatic bile duct dilatation, with a low density lesion (Fig.1A,B). An ERCP showed multiple amorphous filling defects in the bile duct (Fig.2A).
After endoscopic extraction of intrabiliary lesions, a nodular mass was identified in the right intrahepatic duct (Fig.2B). A biopsy specimen revealed a hepatocellular carcinoma with tumor thrombi.
Because the patient refused repeated surgical resection, we designed the peroral direct cholangioscopic APC for intrabiliary tumor control.
Based on a previous study, an ultra-slim upper endoscope (GIF-XP 260, Olympus Corp., Tokyo, Japan) with an outer diameter of 5.0mm was advanced over the guidewire (super-stiff Jagwire; Boston Scientific Corp, Natick, Mass) into the duodenum under fluoroscopic and endoscopic guidance.
During the procedure, however, the guidewire became loose and was dislodged from the biliary system. Therefore, we tried to perform the direct intubation technique without a guidewire.
The endoscope was advanced into the distal common bile duct through the incised papilla in the left and upward direction as a cecal intubation technique during colonoscopic examination.
Then, the patient's abdomen was manually compressed to facilitate advancing the scope to the hilar area.
The cholangioscopic findings noted a green nodular mass in the right intrahepatic duct. An APC (VIO-300D, ERBE Tubingen, Germany) system with a flow rate of 1L/min and power setting of 60W and an APC probe with an outer diameter of 1.5mm was applied for this lesion.
Because of the penetration depth, APC was followed by the debridment of ablated tissue with a biopsy forceps.
There were no procedure-related complications such as bile leaks, perforation, bleeding, cholangitis or pancreatitis.
The follow-up cholangiograpy and subsequent peroral direct cholangioscopy showed no residual mass. The patient remains well during follow-up.
In summary, peroral direct cholangioscopic APC by using an ultra-slim upper endo scope may be an effective and alternative management for recurrent hepatoma with intraductal nodular tumor growth.
| Contributed by: |
Do Hyun Park, M.D. PhD Physician Soon Chun Hyang University Seo Young Yun, MD Soon Chun Hyang University Hospital, Bucheon Tae Hee Kwon, MD Beth Israel Deaconess Medical Center Sang Heum Park, M.D. Soon Chun Hyang University Hospital, Bucheon Suck Ho Lee, MD Soon Chun Hyang University Hospital, Bucheon Jeong Hoon Park, MD Soon Chun Hyang University Hospital, Bucheon Hong-Soo Kim, MD Soon Chun Hyang University Hospital, Bucheon Sun-Joo Kim, MD Soon Chun Hyang University Hospital, Bucheon |
|
Citation: Park PhD, DH & Yun, SY & Kwon, TH & Park, SH & Lee, SH & Park, JH & Kim, H. & Kim, S. (May 21 2007). Biliary - Peroral Direct Cholangioscopic Argon Plasma Coagulation (APC) by Using an Ultra-slim Upper Endoscope for Recurrent Hepatoma with Intraductal Nodular Tumor Growth. The DAVE Project. Retrieved Sep, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=595 Times viewed since Feb 2006: 4518 |
|
