Post written by Margaret G. Keane, MBBS, MSc, from the Department of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA.

A 77-year-old man presented to our institution with jaundice, right upper quadrant pain, loss of appetite, and weight loss. Blood tests confirmed a raised Bilirubin (8.6 mg/dl), abnormal LFTs (Alkaline phosphatase 320 IU/L, AST 86 IU/L, ALT 66 IU/L), and a significantly elevated CA19-9 (3426 U/ml). Cross-sectional imaging by MRI showed intrahepatic biliary dilation above a hilar mass, with multiple solid liver lesions suggestive of metastases.

At ERCP, selective biliary cannulation was achieved with a sphincterotome preloaded with a 0.025-inch guidewire. To visualize the stricture, a single-operator cholangioscope was advanced over the wire. The mucosa of the distal bile duct was relatively normal, but the lumen of the common hepatic duct was narrowed. The mucosa was nodular with neovascularization, highly suggestive of a malignant stricture, and biopsies were obtained via the cholangioscope.

Based on pre-procedural imaging review, this patient had a Bismuth Type IIIa stricture, and our aim was to stent the right anterior and right posterior ducts for optimal drainage. The first wire preferentially went into the right anterior ducts.

Recognizing that cannulation of the right posterior duct would be challenging without cholangioscope visualization and that reintroducing the cholangioscope via the endoscope working channel once a guidewire was already in situ would be impossible, we elected to place a second hydrophilic, 0.025-inch guidewire through the cholangioscope, alongside the first guidewire. Using cholangioscopy, the origin of the right posterior duct could be visualized to enable successful selective segmental wire placement. The cholangioscope was then successfully exchanged over the 2 wires. The stricture was then segmentally dilated, and two 7Fr, 12-cm straight plastic biliary stents were placed. The stents were in a good position at the end of the procedure, draining contrast and bile.

Most patients with hilar cholangiocarcinoma are unresectable at initial presentation, and endoscopic stenting is widely performed for palliation. Normalization of the bilirubin is associated with improved survival, and draining more than half of the liver volume is associated with fewer episodes of cholangitis. Obtaining optimal liver drainage typically requires a single stent in patients with Bismuth type I to II strictures and dual-stent placement in patients with Bismuth type III to IV. Digital, single-operator cholangioscopy is recognized to be a useful tool to aid selective guidewire placement in complex hilar strictures. This case demonstrates that two 0.025-inch guidewires can be placed side-by-side through the cholangioscope to assist with dual-wire placement in complex hilar strictures.

In addition to aiding tissue acquisition and defining tumor extent, single-operator cholangioscopy can direct dual-, 0.025-inch guidewire placement for selective cannulation in complex hilar strictures.

Cholangioscopy-guided double-guidewire technique for bilateral hilar stenting: A, Cholangioscopic view of two 0.025-inch guidewires exiting the cholangioscope. B, Fluoroscopic image confirming guidewire position in the right anterior and right posterior ducts, after cholangioscope-assisted selective cannulation. C, Endoscopic view after cholangioscope exchange, with both guidewires seen exiting the papilla. D, Serial dilation of the hilar stricture with a 4-mm dilation balloon. E, Fluoroscopic image confirming placement of two 7F, 12-cm biliary stents. F, Endoscopic view after bilateral stent placement.

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