Authors Mohit Girotra, MD and Rayburn F. Rego, MD from the Division of Gastroenterology and Hepatology at the University of Arkansas for Medical Sciences (UAMS) in Little Rock, Arkansas, USA share this case “Choledochoscopic surveillance in a patient with Hepaticolithiasi” from the VideoGIE section.
A 54-year-old Asian female with recurrent hepaticolithiasis had previously undergone a Kasai procedure (hepaticojejunostomy) and trisegmentectomy. The patient had a hepaticocutaneous jejunostomy after conventional surgery to allow atraumatic transcutaneous access to the biliary system for the removal of recurrent stones. A regular upper endoscope was used to access the biliary system and clear the duct of stones every 3-4 months. Along with stone removal, careful survey of ducts was performed each time.
This video clip shows choledochoscopy looking at various branches of the biliary system, and you can see we are able to advance quite proximally. During one of these choledochoscopies, nodular mucosa was noted in 2 areas of the left hepatic duct system. Occlusion cholangiogram was obtained, and fluoroscopic image shows dilated bile duct, along with right and left hepatic ducts. Biopsies obtained from the nodular areas revealed biliary duct dysplasia.
Our case demonstrates successful use of choledochoscopy as a potential surveillance tool in hepaticolithiasis, especially in patients with easy access to the biliary system.
Our case has few notable learning points:
- Patients with recurrent hepaticolethiasis may be at high risk for pre-malignant and malignant lesions of the biliary ducts.
- Patients with recurrent hepaticolethiasis may need repeated extraction of stones, and in selected ones with surgically altered anatomy, their extraction may be possible, as in our case.
- In addition to removal of stones, choledochoscopy may be used as an effective surveillance tool in such patients.
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