Spyglass Direct Visualization System facilitatedmanagement of iatrogenic biliary stricture:a novel approach in difficult cannulation

A 70-year-oldmanwith a history of chole-lithiasis underwent laparoscopic chole-cystectomy. At a follow-up visit 2 monthslater, he complained of epigastric pain andweight loss. Alkaline phosphatase, γ-glu-tamyl transferase, and bilirubin levelswere all elevated. Magnetic resonancecholangiopancreatography showed astricture in the middle of the commonbile duct and dilatation above the stric-ture.The patient was referred to us for endo-scopic retrograde cholangiopancreatogra-phy (ERCP), which revealed an iatrogenicstenosis of the common bile duct at thelevel of the junction with the cystic duct,caused by cholocystectomy clips, withdilatation of the bile ducts above thatlevel. Attempts to advance several kindsof guide wires beyond the stricture, in-cluding Jagwire 0.035–0.025 inches (Bos-ton Scientific, Natick, Massachusetts, USA)and angled Terumo (Terumo Europe, Leu-ven, Belgium), were unsuccessful becauseof the severe narrowing and eccentricposition of the opening of the stricturedue to the clip angulation, which causedthe wire to advance only into the cysticduct (●" Fig.1).A decision was made to use the SpyGlassDirect Visualization System (SDVS) (Bos-ton Scientific, Natick, Massachusetts,USA). The SDVS was introduced into thebile duct and a clear visualization of theopenings of the stricture and the cysticduct was achieved (●" Fig.2). Subsequent-ly, the stricture was easily cannulated,dilated, and stented (●" Fig.3).ERCP-guided cholangiopancreatoscopywith SDVS allows direct visualization ofthe bile ducts, tissue sampling, and thera-peutic maneuvers [1–3]. Tight and eccen-tric strictures are a common cause of un-successful cannulation and ERCP failure.In such cases a second ERCP is usuallyattempted and, if unsuccessful, a percuta-neous approach or revision surgery isusually employed. To the best of ourknowledge this is one of the very few re-ported cases of the use of SDVS for chol-angioscopic placement of a guide wireacross a difficult stricture. The first report-ed case concerned an anastomotic stric-

ture in a liver transplant recipient and thesecondone apatientwith ahilar biliary tu-mor [4,5]. We suggest that in cases whereordinary cannulation of an iatrogenic bili-ary stricture fails, the use of SDVS for guid-ed cannulation may represent an alterna-tive, innovative and successful approach.

Endoscopy_UCTN_Code_TTT_1AR_2AG

Competing interests: None

Fig.1 Radiographshowing the tight andeccentric stricture andthe guide wire in thecystic duct.

Fig.2 SpyGlass viewof the openings of thestricture cannulatedwith the Terumo guidewire (blue arrow) andthe cystic duct (blackarrow).

UCTN – Unusual cases and technical notes E433

Theodoropoulou A et al. Spyglass Direct Visualization System facilitated management of iatrogenic biliary stricture: … Endoscopy 2012; 44: E433–E434

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A. Theodoropoulou, E. Vardas,E. Voudoukis, A. Tavernaraki,G. Tribonias, K. Konstantinidis,G. A. Paspatis

Department of Gastroentrology, BenizelionGeneral Hospital, Heraklion, Crete, Greece

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2 Chen YK, Parsi MA, Binmoeller KF et al. Sin-gle-operator cholangioscopy in patients re-quiring evaluation of bile duct disease ortherapy of biliary stones (with videos). Gas-trointest Endosc 2011; 74: 805–814

3 Draganov PV, Lin T, Chauhan S et al. Prospec-tive evaluation of the clinical utility of ERCP-guided cholangiopancreatoscopy with anew direct visualization system. Gastroin-test Endosc 2011; 73: 971–979

4 Wright H, Sharma S, Gurakar A et al. Man-agement of biliary stricture guided by theSpyglass Direct Visualization System in aliver transplant recipient: an innovativeapproach. Gastrointest Endosc 2008; 67:1201–1203

5 Bhat YM, Kochman ML. Novel managementof complex hilar biliary strictures with theSpyglass Direct Visualization System (withvideo). Gastrointest Endosc 2009; 69:1182–1184

BibliographyDOI http://dx.doi.org/10.1055/s-0032-1325857Endoscopy 2012; 44: E433–E434© Georg Thieme Verlag KGStuttgart · New YorkISSN 0013-726X

Corresponding authorG. A. Paspatis, MDDepartment of GastroenterologyBenizelion General HospitalL. Knossou71409 HeraklionCreteGreeceFax: +30-2810-368017paspati@admin.teiher.gr

Fig.3 Radiographshowing the biliarystenosis dilated by aballoon dilator.

Theodoropoulou A et al. Spyglass Direct Visualization System facilitated management of iatrogenic biliary stricture: … Endoscopy 2012; 44: E433–E434

UCTN – Unusual cases and technical notesE434

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