Direct peroral ultraslim endoscopy-guided biliary drainage in a patient with cystic duct carcinoma and an occluded self-expandable metallic stent.

Direct biliary drainage using ultraslim endoscopes has been developed for treating acute cholangitis. We present a case wherein direct biliary drainage with ultraslim endoscopy was successfully used in the setting of an occluded a partially covered self-expandable metallic stent (PC-SEMS) in a patient with unresectable cystic duct carcinoma and duodenal stenosis. A 72-year-old man presented with acute cholangitis due to locally advanced cystic duct carcinoma. He had undergone PCSEMS placement for distal biliary obstruction 11 months previously, followed by chemotherapy. This was the third time he had experienced sludge-related PC-SEMS obstruction. Esophagogastroduodenoscopy revealed rapid tumor growth with asymptomatic gastric outlet obstruction (●" Fig.1) that had not been observed at the most recent PC-SEMS occlusion (1 month previously). A standard duodenoscope could not pass through the obstructed gastric outlet; therefore, we attempted direct biliary drainage using an ultraslim endoscope (GIF XP260N; Olympus Medical Systems, Tokyo, Japan) (●" Fig.2). The outer diameters of the endoscopy insertion tube and of the distal end were 5.0mm and 5.5mm, respectively; the instrument channel diameter was 2.0mm. Direct peroral cholangioscopy was performed through the PC-SEMS. We confirmed that the PC-SEMS dysfunction was caused by sludge and food impaction (●" Fig.3,●" Video 1). A 5-Fr nasobiliary drainage catheter was used to obtain a retrograde cholangiogram (●" Fig.4, ●" Video 1), which revealed tumor overgrowth (●" Fig.5,●" Video 1). Finally, two cut 5-Fr nasobiliary drainage catheters were successfully placed through the PC-SEMS under direct peroral cholangioscopy guidance, without any complications (●" Fig.6,●" Video 1). Direct peroral cholangioscopy-guided biliary drainage using ultraslim endoscopes has recently been employed for treating acute cholangitis [1–3]. Itoi et al. reported Fig.2 Radiograph showing an ultraslim endoscope passing through the obstructed gastric outlet.