Intrabiliary resection of metastasis originating from colorectal carcinoma during direct peroral cholangioscopy: a new tool for biliary palliation.

Intrabiliary growth of a liver metastasis originating from colorectal carcinoma is a rare manifestation of metastatic liver carcinoma, with only a few cases reported in the literature [1–3]. Radiological characteristics of the “classic” liver metastases are well established, and generally preoperative biopsy to plan a proper surgical strategy is not required. However, the radiological features of intrabiliary liver metastasis may not be distinctive, leading to possible misdiagnosis. We present the case of an 83-year-old woman who was referred to our unit because of jaundice. The medical history reported left hemicolectomy for cancer (pT3N0) 15 years earlier and hepatic segmentectomy for metastatic nodule 5 years earlier. Computed tomography and magnetic resonance imaging scans showed dilation of the common bile duct and intrahepatic bile ducts, with an intraductal nodule at the hepatic hilum (▶Fig. 1). Carcinoembryonic antigen and α-fetoprotein levels were normal. Endoscopic retrograde cholangiopancreatography showed a dilated biliary duct (14mm) with a “negative” image of about 20mm at the bifurcation. After sphincterotomy and papilloplasty up to 12mm, direct peroral cholangioscopy (POC) was performed using a slim scope (8.5mm diameter, EG 530FP; Fujifilm, Tokyo, Japan). A polypoid mass with irregular vascular pattern, highly suggestive of malignancy, was observed at the hepatic hilum (▶Fig. 2 a). Endoscopic resection of the lesion, under direct visualization, with a hot snare (15mm, Captivator II; Boston Scientific Corp., Marlborough, Massachusetts, USA) was performed, thus avoiding the need for biliary stent placement (▶Fig. 2b, ▶Video1). Histology revealed a metastasis of colorectal carcinoma (▶Fig. 3). The patient remained free of symptoms with normal bilirubin level for 12 months. To our knowledge this is the first case of an intrabiliary endoscopic resection performed under direct visualization. The POC is an advanced technique for intraluminal visual inspection and for therapeutic intervention of the biliary ducts [4], and shows potential as a promising approach in the diagnosis and treatment of a subgroup of patients with biliary obstruction secondary to intraductal masses.