Percutaneous transhepatic cholangioscopy for the diagnosis of biliary obstruction in a patient with Roux-en-Y partial gastrectomy

Published:August 01, 2016DOI:
      A 71-year-old man who had undergone a Roux-en-Y partial gastrectomy and adjuvant chemoradiation for gastric adenocarcinoma 4 years earlier presented with obstructive jaundice. CT and MRI confirmed common bile duct (CBD) obstruction at the pancreatic “plateau” with no obvious expansive lesion (Fig. 1A). Transhepatic percutaneous drainage with a 10F pigtail was performed for relief of the jaundice. In consideration of a possible primary biliary neoplasia and the good clinical status of the patient, a differential diagnosis of metastatic gastric adenocarcinoma was important. For primary biliary adenocarcinoma, a Whipple procedure would be indicated. For gastric metastasis, the treatment would be palliative chemotherapy. A percutaneous transhepatic cholangioscopy with a 4.9 mm endoscope through the percutaneous tract was planned to obtain tissue for histologic diagnosis (Video 1, available at In the first attempt, biliary access was not possible despite 6-mm balloon dilation of the percutaneous tract. At the end of the procedure the 10F drain was exchanged for a 14F drain. The second attempt, 14 days later, was successful, with visualization of a whitish vegetating lesion in the distal CBD (Fig. 1B). Biopsy specimens were taken with forceps. The final pathologic examination with immunohistochemistry suggested a diagnosis of metastatic gastric adenocarcinoma.
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      Figure 1A, MRI confirmed obstruction of the CBD. B, Vegetating lesion in the distal CBD.
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