Endoscopic resection of hilar papillomatosis after Whipple procedure for ampullary adenoma

A 73-year-old female presented for definitive treatment of biliary papillomatosis after a Whipple procedure 5 years prior for an ampullary adenoma with intraductal extension (Video 1, available online at www.giejournal.org). Most recently, she developed abnormal liver chemistries and intrahepatic bile duct dilatation on CT imaging. ERCP was attempted locally but failed. PTC demonstrated a hilar mass, and bilateral biliary drainage catheters were placed. Cholangioscopic biopsy specimens revealed histologic findings consistent with biliary papillomatosis, a rare entity characterized by multiple small papillary adenomas of the biliary tree. The pathogenesis of these lesions is incompletely understood; however, biliary papillomas are known to have a high malignant potential. In this case, the patient declined surgery and was referred to our institution for endoscopic options. Initially, the biliary catheters were injected revealing a large filling defect at the bifurcation. An intraductal ultrasound probe further characterized this echogenic, multilobulated polypoid mass. A single-balloon enteroscope was passed into the afferent limb near the hepaticojejunal anastomosis. A guidewire was grasped with a snare and the snare was pulled from the enteroscope through the anastomosis and out the percutaneous site allowing enteroscope advancement through the hepaticojejunostomy into the common hepatic duct. The lesion was visualized and completely resected using a variety of standard accessories, making internal drainage unnecessary. No residual obstruction was evident endoscopically or cholangiographically. The patient remained free of papilloma recurrence on 2 surveillance choledochoscopies over the subsequent 18 months. This case demonstrates that endoscopic therapy to the proximal bile duct is feasible in patients with surgically altered anatomy; however, advancement to the anastomosis remains challenging (Fig. 1).