Post written by Sooraj Tejaswi, MD, MSPH, from the Division of Gastroenterology & Hepatology, University of California Davis School of Medicine, Sacramento, California.

We describe the collaborative effort of the use of the novel short cholangioscope-aided percutaneous retrieval of a plastic biliary stent after being unable to retrieve the stent during ERCP. The patient was a 74-year-old male who, post cholecystectomy, presented to us with abnormal LFTs, with an MRI finding of a high-grade common hepatic duct/hilar stricture and filling defect in the right intrahepatic duct. Due to concern for cholangiocarcinoma, we undertook cholangioscopy and found a surgical staple embedded in the mucosa of the common hepatic duct (CHD), with a stone proximal to it. Due to the high-grade stricture, we could not access or remove the stone despite balloon dilation of the stricture, and hence we placed a 7F stent across this stricture, with a plan to repeat the procedure in a few months and to allow the stone a chance to reduce in size and/or disintegrate from repeated friction against the stent. The stent could not be retrieved during repeat ERCP as its proximal flap was entrapped above the high-grade stricture in the CHD.

At this point, we decided to perform percutaneous cholangioscopic retrieval of the entrapped stent along with our IR colleagues. We had been doing this with the digital cholangioscope originally designed for retrograde cholangioscopy, but had found it harder to handle the cholangioscope due to its length. Hence, we decided to use the novel short (65 cm) digital cholangioscope. Based on ex-vivo assessment, we realized that a 12F percutaneous sheath would easily accommodate the digital cholangioscope, and we used the same size sheath for this case as well. It has been our practice to perform same-session percutaneous biliary access, sheath placement, and cholangioscopy, instead of waiting for the percutaneous biliary tract to mature for several weeks prior to attempting percutaneous cholangioscopy. However, to avoid the risk of bile leak, we left the percutaneous biliary sheath in place for 6-8 weeks post procedure before attempting its removal.

In this case, we demonstrated the use of the snare designed for use with the digital cholangioscope to retrieve the biliary stent percutaneously. Management of plastic biliary stents entrapped above high-grade strictures, or those that have migrated proximally in the bile duct, can be challenging. Percutaneous cholangioscopy adds to the limited armamentarium of devices and techniques to address this issue without need for a more invasive option like surgery.

The availability of the novel short digital cholangioscope is a significant step forward in percutaneous cholangioscopy. Due to the shorter length and more flexible tip, this cholangioscope is ideal for percutaneous biliary interventions such as retrieval of stents and also for diagnosis of biliary strictures when retrograde cholangioscopy fails or is not an option.

Difficult anatomies that previously precluded retrograde cholangioscopy can be amenable for percutaneous cholangioscopy. The novel short cholangioscope makes is easier to maneuver the biliary tree from this antegrade/percutaneous approach. Coordination with IR team is essential for this procedure. The procedure can be performed as a same-session procedure, but it is important to leave the percutaneous biliary drain in place to avoid the risk of bile leak if the drain is removed prematurely. The patient needs to be informed about the various steps involved and the time frame.

Decisiveness in identifying patient anatomies that would benefit from percutaneous cholangioscopy, will avoid unnecessary and failed ERCPs, and expedite patient care. It is likely that the interventional radiologist may perform percutaneous cholangioscopies independently, with input requested from gastroenterologists as needed.

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