The accidental discovery of pancreatic ductal adenocarcinoma on percutaneous cholangioscopy through a T-tube tract

 

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A 58-year-old man with pancreatitis underwent contrast-enhanced computed tomography and was found to have gallstones. He therefore underwent cholecystectomy and intraoperative choledochoscopy at his local hospital, during which some sediment-like stones were removed from the common bile duct (CBD), and a T-tube was left in place. Postoperative cholangiography through the T-tube showed obstruction in the distal CBD ([Fig. 1]) and he was therefore transferred to our center for further diagnosis and treatment.

We had been intending to perform endoscopic retrograde cholangiopancreatography (ERCP) for this patient, but ended up conducting percutaneous cholangioscopy through the T-tube tract because the patient took food by mistake on the day of the operation. The procedure was performed as follows: first, a guidewire was inserted into the duodenum through the T-tube, which was confirmed radiographically ([Fig. 2]); subsequently, a high definition cholangioscope (eyeMax, 9 Fr; Micro-Tech) was inserted into the CBD and then the duodenum over the guidewire ([Fig. 3]). We found circumferential villous structures in the distal CBD, and a biopsy taken under cholangioscopic guidance showed adenocarcinoma ([Video 1]). The patient therefore underwent contrast-enhanced magnetic resonance imaging and a suspected lesion was found in the pancreatic head. The patient eventually underwent pancreaticoduodenectomy and the pathology turned out to be pancreatic ductal adenocarcinoma (PDAC) [1] invading the CBD.

Video 1 The features of pancreatic ductal adenocarcinoma invading the common bile duct on percutaneous cholangioscopy performed through a T-tube tract.

To date, reports focusing on the cholangioscopic features of PDAC invading the CBD are rare. This study showed the typical villous structures of PDAC invading the CBD ([Fig. 4 a]). Moreover, the differential diagnosis on cholangioscopic imaging between cholangiocarcinoma and PDAC invading the CBD is an important issue. Based on our experience, cholangiocarcinoma tends to present as an obvious lesion with a pale bottom and red top with thick and tortuous vessels ([Fig. 4 b]). This study has also confirmed that a T-tube provides an alternative tract for cholangioscopy in certain circumstances.

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^* Joint first authors

Publication History

Article published online:
03 February 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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• Reference

• 1 Dhillon J, Betancourt M. Pancreatic ductal adenocarcinoma. Monogr Clin Cytol 2020; 26: 74-91
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