Cholangioscopy-guided laser ablation for intraductal papillary neoplasm of bile duct

A 65-year-old man with a history of metastatic bladder cancer was admitted with jaundice. Blood tests revealed a cholestatic pattern of liver function, hyperbilirubinemia, and deranged clotting profile. Computed tomography and magnetic resonance cholangiopancreatography showed cirrhosis and dilated extrahepatic and intrahepatic biliary systems without hyperdense stones ([Fig. 1]). Endoscopic retrograde cholangiopancreatography revealed a fish-mouth deformity of the papillary opening ([Fig. 2]), dilated intrahepatic ducts, and poor contrast filling of the common bile duct ([Fig. 3]). Repeated balloon trawling (18 mm) yielded a copious amount of jelly-like mucus. Cholangioscopy (SpyGlass; Boston Scientific, Natick, Massachusetts, United States) revealed multiple foci of papillary growth in the upper common bile duct, common hepatic duct, and proximal left biliary duct ([Fig. 4]). The biopsy samples revealed papillary proliferation with a gastric subtype and low-grade dysplasia. A diagnosis of intraductal papillary neoplasm of the bile duct (IPNB) was made. Repeat cholangioscopy was performed by introducing an end-on irradiation fiber connected to a laser system (Leonardo 1470 nm/980 nm dual-wavelength laser; CeramOptec GmbH/Biolitec AG, Bonn, Germany) ([Fig. 5]). Ablation of the papillary growth was performed until a whitish discoloration and necrosis appeared ([Video 1]). The patient did not experience any discomfort or adverse events after the procedure and was discharged 9 days later.