A dual-modality approach of endobiliary radiofrequency ablation and self-expandable metal stent placement to control malignant hemobilia.

A 69-year-old man with a history of metastatic pancreatic cancer involving the head of the pancreas and previous placement of an uncovered self-expandable metal stent (SEMS) for malignant biliary obstruction presented to the hospital with new-onset jaundice, melena, and a drop in hemoglobin from 11.0 to 5.6 g/dL over 2 weeks. Given his clinical picture, an urgent upper endoscopy and endoscopic retrograde cholangiopancreatography (ERCP) were performed (▶Video1). ERCP demonstrated brisk hemobilia with cholangiogram evidence of stent obstruction, which was most likely secondary to tumor ingrowth (▶Fig. 1 a, ▶Video1). Balloon sweeps of the bile duct confirmed suspicion of bleeding from the diffuse tumor ingrowth. Endobiliary radiofrequency ablation (RFA) was performed for tumor destruction and hemostasis (▶Fig. 1b, ▶Video1). This was chosen as the initial treatment approach because, given the degree of blood loss, it was important to confirm control of bleeding prior to placement of a covered SEMS. The entire length of the stent was fulgurated with the RFA probe at 10 watts for 90 seconds in sequential fashion. As a result, there was prompt cessation of hemobilia (▶Fig. 1 c, ▶Video1). A fully covered SEMS was placed within the uncovered metal stent to prevent continued tumor ingrowth. The patient had no further evidence of bleeding following the intervention, and hemoglobin levels stabilized. Endoscopic interventions are limited for hemobilia and have historically relied on the tamponade physiology of fully covered SEMS [1–3]. This case presents a E-Videos