Directed balloon-assisted guidewire access into intrahepatic ducts

Selective intrahepatic duct cannulation by using a triple-lumen catheter for endoscopic bilateral stenting in hilar cholangiocarcinoma

BACKGROUND

Selective cannulation of the intrahepatic duct is essential for endoscopic management of hilar cholangiocarcinoma, but it can be very difficult to achieve. Preexisting methods are sometimes time consuming and have limited success.

OBJECTIVE

To evaluate the effectiveness of a triple-lumen catheter for selective cannulation in the intrahepatic ducts of patients with hilar cholangiocarcinoma.

DESIGN

Retrospective analysis of a prospective database.

SETTING

Tertiary-care referral university hospital.

PATIENTS

This study involved 58 patients with unresectable hilar cholangiocarcinoma (Bismuth types II-IV), in whom attempts were made to insert bilateral stents endoscopically.

INTERVENTION

After conventional cannulation methods failed, selective cannulation with a triple-lumen catheter was tried.

MAIN OUTCOME MEASUREMENTS

Selective cannulation of the left or right intrahepatic duct.

RESULTS

With the triple-lumen catheter, the rates of successful selective intrahepatic duct cannulation increased from 97% (56/58 patients) to 100% (58/58 patients) in the first stent (Y stent) placement site and from 78% (45/58 patients) to 91% (53/58 patients) in the second (contralateral stent) placement site. Selective cannulation with the triple-lumen catheter was achieved in 10 of 15 patients (67%) in whom conventional methods failed. When the triple-lumen catheter was used, the success rate of guidewire insertion into the bilateral intrahepatic ducts was increased from 74% (43 patients) to 91% (53 patients).

LIMITATIONS

Retrospective, single-center study.

CONCLUSIONS

Use of the triple-lumen catheter appears to be an effective method for selective cannulation of intrahepatic ducts. It can be considered as a valuable method for selective cannulation in patients with hilar cancer in whom conventional methods have failed.

Selective intrahepatic ductal cannulation during ERCP with a sphincterotome

BACKGROUND

Selective intrahepatic ductal cannulation during ERCP remains difficult, particularly when strictures involve the bifurcation and/or secondary intrahepatic branches.

METHODS

A retrospective review was conducted of a cohort of 16 patients (stones 5, cholangiocarcinoma 5, primary sclerosing cholangitis 4, hepatoma 1, bile leak 1) in whom selective cannulation of the intrahepatic ducts with conventional techniques was unsuccessful and who underwent ERCP with a sphincterotome and a hydrophilic coated guidewire to achieve intrahepatic ductal access.

RESULTS

The procedure was technically successful in 15 patients and clinically successful in 12. In the 5 patients with bile duct stones, clearance was obtained in 3 and stents were placed in the other 2 patients; one died of cholangitis within 30 days and the other underwent surgery. The procedure was technically successful in 3 of the 5 patients with cholangiocarcinoma. One patient died and the procedure was technically unsuccessful in another. For all patients with primary sclerosing cholangitis, the endoscopic therapy was technically successful and clinical outcomes satisfactory. The patient with a hepatoma was treated successfully and subsequently died of hepatic failure.

CONCLUSION

Use of a sphincterotome and hydrophilic-coated guidewire can significantly enhance the success rate for selective intrahepatic ductal access.