Direct visualization of biliary stricture through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy

Bile duct visualization in surgically altered anatomy can be challenging. We describe a simple technique of colonoscope-assisted cholangioscopy (CAC) to evaluate a biliary stricture in a patient with Roux-en-Y hepaticojejunostomy (RYHJ). A 57-year-old man with a history of distal common bile duct cholangiocarcinoma presented with abdominal pain and weight loss. He had undergone RYHJ 5 years earlier and was in remission. His liver tests showed cholestasis (bilirubin 35 μmol/L, alkaline phosphatase 2215 U/L). The MRCP showed a stricture suggestive of recurrence at the hepatic duct confluence. We performed ERCP with use of a pediatric colonoscope (Olympus, PCF-PH 190, Center Valley, Pa): outer diameter 9.7 mm, working length 1680 mm, working channel 3.2 mm, equipped with cap and water-jet function. By maintaining a straight colonoscope, we cannulated the duct and dilated the stricture. We performed brush cytology to exclude metachronous cholangiocarcinoma and placed a plastic stent (8.5F) for drainage. Cytologic assessment showed atypical cells. We repeated the procedure using an adult colonoscope (Olympus, CF-HQ190A/L) and introduced a cholangioscope (Spyglass-DS, Boston Scientific, Marlborough, Mass) through the working channel (Fig. 1; Video 1, available online at www.giejournal.org). The presence of the stent enabled the cholangioscope to advance further into the bile duct. Cholangioscopy showed a benign stricture without worrisome features and multiple stones, which were removed, resulting in symptom resolution. In conclusion, CAC can be performed in RYHJ to enable a precise diagnosis.