Direct peroral cholangioscopy combined with argon plasma and radio-frequency ablation in restoring the patency of a self-expandable metal stent

A 74-year-old man was presented to our department with obstructive jaundice due to obstruction of an uncovered, self-expandable metal stent. Previously, he underwent an emergency cholecystectomy due to cholecystitis. He was readmitted to our unit 7 days after the procedure due to obstructive jaundice, fever, and severe upper abdominal pain. His white blood count (WBC) was 22.3 × 109/l, and his C-reactive protein (CRP) was 283.4 mg/l. An abdominal computed tomography (CT) scan showed dilation of the intrahepatic bile ducts. The patient was deemed unfit for major surgery due to his comorbidities: hypertension, ischaemic heart disease with heart failure, and type II diabetes. So, an initial endoscopic approach was chosen. During endoscopic retrograde cholangiopancreatography (ERCP) we discovered a stricture of the common hepatic duct opposite a pair of metallic surgical clips. Many attempts of balloon dilation and plastic stent insertion failed. As a last resort, we successfully inserted an uncovered self-expandable metallic stent (10 × 80 mm); we did not opt for a covered stent due to a high risk of migration. The patient was discharged 5 days after this procedure. After 12 months, the patient was readmitted due obstructive, painless jaundice. A contrast enhanced abdominal magnetic resonance imaging (MRI) examination showed a narrowing of the present SEMS lumen. As before, the patient was deemed unfit for surgery, so an endoscopic procedure was preferred.
Several initial ERCPs proved unsuccessful in restoring the patency of the stent. Multiple biopsies and cytology brush sweeps were taken to rule out the presence of a neoplastic lesion. Also, an initial diagnostic cholangioscopy (DPOC) showed only scar tissue obstructing the stent’s lumen.
The patient was qualified for a direct peroral cholangioscopy (DPOC) combined with argon plasma (APC) and radio-frequency (RF) ablation to restore the patency of the biliary stent.
We used an ultra slim gastroscope with a diameter of 5.7 mm (PENTAX Medical, EG17-i10) and a working channel of 2.0 mm. During the procedure we used CO2 insufflation. After performing a re-papillotomy and papilla balloon dilation, we accessed the common bile duct using the “J” manoeuvre. After ascending to the common hepatic duct, the obstructed stent and the scarring of surrounding tissue were visualised (Figure 1). Using an APC probe (Figure 2) in a sweep motion (cranial to caudal), we made about 10 passes, creating a 3 mm...


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