Case Report The Korean Journal of Pancreas and Biliary Tract 2015;20: pissn eissn 2288-

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1 Case Report The Korean Journal of Pancreas and Biliary Tract 2015;20: pissn eissn 총담관 - 십이지장문합부위를통한직접경구담관내시경하담관내고주파열치료를시행한악성담관폐쇄 1 예 부산대학교의과대학부산대학교병원내과 강진숙 김동욱 이정은 김민지 송근암 허정 백동훈 김태욱 A Case of Direct Peroral Cholangioscopy-Guided Intraductal Radiofrequency Ablation for Malignancy Biliary Obstruction via Choledochoduodenostomy Orifice Jin Suk Kang, Dong-Uk Kim, Jeong Eun Lee, Min Ji Kim, Geun Am Song, Jeong Heo, Dong Hoon Baek, Tae Wook Kim Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea BAlthough intraductal radiofrequency ablation (RFA) has been reported to be a feasible treatment of malignancy biliary obstruction in unresectable cholangiocarcinoma, endoscopic retrograde cholangiopancreatography (ERCP)- guided intraductal RFA has a disadvantage that cannot be directly visualize the biliary tract using the fluoroscopic image. On the other hand, direct peroral cholangioscopyguided intraductal RFA is easy to insert catheter and apply treatment by visualizing the bile duct lesions. We present a case of direct peroral cholangioscopyguided intraductal RFA without biliary stent in 67-year-old woman patient with cholangiocarcinoma for treatment of malignancy biliary obstruction. In the past, she underwent choledochoduodenostomy for intrahepatic stones. She underwent direct peroral cholangioscopy-guided intraductal RFA via choledochoduodenostomy orifice, and biliary patency was preserved for 90days without additional treatment such as biliary stent and severe complication. Direct peroral cholangioscopy-guided intraductal RFA is expected to be able to reduce the complications of the procedure by ensuring the bile duct lesions. Prospective studies with long term follow up are warranted. Keywords: Cholangiocarcinoma, Intraductal radiofrequency ablation, Direct peroral cholangioscopy Received May. 14, 2015 Revised Jun. 14, 2015 Accepted Jun. 23, 2015 Corresponding author : Tae Wook Kim Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan , Korea Tel Fax ; taewook80@hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2015 by The Korean Journal of Pancreas and Biliary Tract 서론 (cholangiocarcinoma) 10-20%, %. 2 50%,., 140 Copyright 2015 by Korean Pancreatobiliary Association

Jin Suk Kang, et al.. 3, 4,5. (self expandable metal stent), (chemotherapy), (photodynamic therapy) 6., (intraductal RFA). 2,7,,, 3, 218, 115.

30 (left lateral and posterior hepatic segmentectomy), (cholecystectomy). 10 (biliary cirrhosis). 18, Bismuth 4 (stage I, T1N0M0) (Fig. 1A).

(A) Abdominal computed tomography scan shows soft tissue density at hepatic hilum with mild dilatation of the intrahepatic bile duct at the time of

2 Jin Suk Kang, et al.. 3, 4,5. (self expandable metal stent), (chemotherapy), (photodynamic therapy) 6., (intraductal RFA). 2,7,,, 3, 218, , ( 9.6 vs. 7.5, p =0.799). 9. 2,. (direct peroral cholangioscopy) (slim gastroscope),. 10 (choledochoduodenostomy). 증례 (left lateral and posterior hepatic segmentectomy), (cholecystectomy). 10 (biliary cirrhosis). 18, Bismuth 4 (stage I, T1N0M0) (Fig. 1A). Gemcitabine Cisplatin 9.. A B C Fig. 1. (A) Abdominal computed tomography scan shows soft tissue density at hepatic hilum with mild dilatation of the intrahepatic bile duct at the time of diagnosis. (B) Abdominal computed tomography scan shows stricture at hepatic hilum and dilatation of the intrahepatic bile duct at the time of admission. (C) Fluoroscopic finding before intraductal radiofrequency ablation shows obstructed common hepatic duct and both intrahepatic bile duct. 141

Direct Peroral Cholangioscopy-Guided Intraductal Radiofrequency Ablation,.. 7.7 g/dl, 3,210/mm 3, 50,000/mm 3, AST/ALT 33/18 IU/L, ALP 157 IU/L r-gt 69 IU/L, total bilirubin 6.

5 Fr, 2.2 cm ELRA (STARmed, Goyang, Korea), 10 W 120, 80 75 (Fig. 2).. 38. 4. 7.. 7.5 Fr, 1.8 cm 10 W 120 75-80. 10. (Fig. 3). Cefotaxime Metronidazole A B Fig. 2. Direct peroral cholangioscopy guided intraductal radiofrequency ablation was performed through choledochoduodenostomy orifice in a 67-year-old woman with cholangiocarcinoma (Bismuth type IV).

3 Direct Peroral Cholangioscopy-Guided Intraductal Radiofrequency Ablation, g/dl, 3,210/mm 3, 50,000/mm 3, AST/ALT 33/18 IU/L, ALP 157 IU/L r-gt 69 IU/L, total bilirubin 6.17 mg/dl, direct bilirubin 4.38 mg/dl, amylase/lipase 90.0/57.7 U/L, CA U/mL, CRP 4.34 mg/dl. (Computed tomography) (Fig. 1B).. GIF-XP260 (Olympus Co., Tokyo, Japan) -.. (Fig. 1C).., 7.5 Fr, 2.2 cm ELRA (STARmed, Goyang, Korea), 10 W 120, (Fig. 2) Fr, 1.8 cm 10 W (Fig. 3). Cefotaxime Metronidazole A B Fig. 2. Direct peroral cholangioscopy guided intraductal radiofrequency ablation was performed through choledochoduodenostomy orifice in a 67-year-old woman with cholangiocarcinoma (Bismuth type IV). (A) Cholangioscopic view shows obstructed common hepatic duct for cholangiocarcinoma. (B) Fluoroscopic findings shows inserted the RFA catheter at right hepatic duct

with fluoroscopy was performed. (A) In cholangioscopic view, there was no complications perforation and bleeding.

4 Jin Suk Kang, et al. A B Fig. 3. After direct peroral cholangioscopy guided intraductal radiofrequency ablation, follow up direct peroral cholangioscopy with fluoroscopy was performed. (A) In cholangioscopic view, there was no complications perforation and bleeding. (B) Fluoroscopic finding shows the biliary patency is preserved.,,. 11 total bilirubin direct bilirubin 2.61 mg/dl 1.92 mg/dl , 고찰,.,. 3, ,12 1,11.,,. 2,7, 170 ( 218, 115 ), 10.6, , 143

5 Direct Peroral Cholangioscopy-Guided Intraductal Radiofrequency Ablation ,,,. 9,,. 3,7,8,11,,, ,,,,,. 1,2. Choi 12, 9 7 (77.8%),. (mother-baby scope) overtube mm 2 mm. 12,13.,..,. 14,15 sump, 요약,,.,.. 국문색인 : 담관암, 담관내고주파열치료, 직접경구담관내시경 144

6 Jin Suk Kang, et al. Conflicts of Interest No conflict among authors. REFERENCES 1. Tal AO, Vermehren J, Friedrich-Rust M, et al. Intraductal endoscopic radiofrequency ablation for the treatment of hilar non-resectable malignant bile duct obstruction. World J Gastrointest Endosc 2014;6: Roque J, Ho SH, Reddy N, Goh KL. Endoscopic ablation therapy for biliopancreatic malignancies. Clin Endosc 2015;48: Sharaiha RZ, Natov N, Glockenberg KS, Widmer J, Gaidhane M, Kahaleh M. Comparison of metal stenting with radiofrequency ablation versus stenting alone for treating malignant biliary strictures: is there an added benefit? Dig Dis Sci 2014;59: Soderlund C, Linder S. Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial. Gastrointest Endosc 2006;63: Kaassis M, Boyer J, Dumas R, et al. Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study. Gastrointest Endosc 2003;57: Lee TY, Cheon YK, Shim CS, Cho YD. Photodynamic therapy prolongs metal stent patency in patients with unresectable hilar cholangiocarcinoma. World J Gastroenterol 2012;18: Rustagi T, Jamidar PA. Intraductal radiofrequency ablation for management of malignant biliary obstruction. Dig Dis Sci 2014;59: Dolak W, Schreiber F, Schwaighofer H, et al. Endoscopic radiofrequency ablation for malignant biliary obstruction: a nationwide retrospective study of 84 consecutive applications. Surg Endosc 2014;28: Strand DS, Cosgrove ND, Patrie JT, et al. ERCP-directed radiofrequency ablation and photodynamic therapy are associated with comparable survival in the treatment of unresectable cholangiocarcinoma. Gastrointest Endosc 2014;80: Parsi MA. Direct peroral cholangioscopy. World J Gastrointest Endosc 2014;6: Steel AW, Postgate AJ, Khorsandi S, et al. Endoscopically applied radiofrequency ablation appears to be safe in the treatment of malignant biliary obstruction. Gastrointest Endosc 2011;73: Choi HJ, Moon JH, Ko BM, et al. Clinical feasibility of direct peroral cholangioscopy-guided photodynamic therapy for inoperable cholangiocarcinoma performed by using an ultra-slim upper endoscope (with videos). Gastrointest Endosc 2011;73: Moon JH, Terheggen G, Choi HJ, Neuhaus H. Peroral cholangioscopy: diagnostic and therapeutic applications. Gastroenterology 2013;144: Rosch W, Koch H. Peroral cholangioscopy in choledocho-duodenostomy--patients using the pediatric fiberscope. Endoscopy 1978;10: Choi HJ, Moon JH, Lee YN, et al. Direct insertion of an ultra-slim upper endoscope for cholangioscopy in patients undergoing choledochoduodenostomy. Dig Endosc [Epub ahead of print] 145

Dae Won Park, et al.. 1,2 POC (electrohydraulic lithotripsy, EHL) 1. 증례 , 64, 18, 140/80 mmhg... 4,400/mm³, 10.8 g/dl, 232,000/mm³. 131

Dae Won Park, et al.. 1,2 POC (electrohydraulic lithotripsy, EHL) 1. 증례 , 64, 18, 140/80 mmhg... 4,400/mm³, 10.8 g/dl, 232,000/mm³. 131 Case Report The Korean Journal of Pancreas and Biliary Tract 2015;20:146-150 http://dx.doi.org/10.15279/kpba.2015.20.3.146 pissn 1976-3573 eissn 2288-0941 경구담도내시경후발생한간내담도천공의증 1 예 광주기독병원소화기내과 박대원 박상욱 김두진