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Successful management of ischemic cholangiopathy after failed endoscopic/percutaneous interventions, facilitated by digital cholangioscopy

      A 63-year-old man who had undergone liver transplantation for hepatitis C experienced cholestasis 1.5 years later, which was initially assumed to be due to choledocholithiasis but was later established to be ischemic cholangiopathy secondary to hepatic artery thrombosis. This finding, which was not seen on any prior noninvasive imaging, was established by a hepatic angiogram, which was obtained after the failure of ERCP and percutaneous pranshepatic cholnagiography (PTC) attempts to gain access into the biliary system. Repeated ERCP with cholangioscopy was undertaken as a surgery-sparing “rescue strategy,” and necrotic material and bile plugs were patiently debulked to allow the passage of a wire to perform dilation of the biliary stricture. These interventions allowed the advancement of a cholangioscope farther up, the establishment under direct visualization of preferential access to the intrahepatic ducts to clear more necrotic material and bile ducts (Fig. 1), and finally successful stent placement (Video 1, available online at www.giejournal.org). To the best of our knowledge, this is the first reported case of such complicated endoscopic management of ischemic cholangiopathy, using a digital cholangioscope, which allowed the identification and removal of occluding bile casts and necrotic material and consequent successful stricture dilation and stenting. This innovative technique served as a surgery-sparing “rescue approach” in our patient with prior failure of endoscopic and percutaneous biliary access and interventions.
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      Figure 1Through-the-cholangioscope forceps removal of the bile plugs.
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