identiﬁed. A 19-G needle was used to puncture the balloon. Contrast medium was injected through the needle under ﬂuoroscopy to conﬁrm the needle position within the small bowel. A second 0.035-inch hydrophilic wire was advanced through the needle and coiled within the lumen of the bowel. A needle-knife was used to dissect the ﬁstulous tract. A 4 mm 4 cm balloon was used to dilate the ﬁstulous tract. A 15 mm 10 mm lumen-apposing metal stent was then deployed under a combination of ﬂuoroscopic, endoscopic, and echosonographic guidance (Fig. 1) (Video 1, available online at www.giejournal.org). The stent position was conﬁrmed by direct endoscopic visualization and on ﬂuoroscopy. A controlled radial expansion balloon was used to dilate the lumen of the stent to 13.5 mm. The patient’s obstructive symptoms improved immediately after the procedure. She was given a liquid diet on postoperative day 1.
DISCLOSURE The following author disclosed ﬁnancial relationships relevant to this publication: M. Kahaleh, consultant for Boston Scientiﬁc and Xlumina; research support from Gore, MI Tech, and Pinnacle; and consultant for and research support from Maunakea. All other authors disclosed no ﬁnancial relationships relevant to this publication. Amy Tyberg, MD, Nikhil Kumta, MD, Kunal Karia, MD, Steven Zerbo, Reem Z. Sharaiha, MD, Michel Kahaleh, MD, FASGE, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
Cholangioscopy-assisted photodynamic therapy for cholangiocarcinoma
Figure 1. Cholangioscopy demonstrating diffuse necrosis of the biliary cancer after PDT.
A 62-year-old man with unresectable cholangiocarcinoma underwent ERCP with photodynamic therapy (PDT) under cholangioscopic guidance. Forty-eight hours before this pro-
cedure, the patient was injected with Photofrin (Pinnacle Biologics, Bannockburn, Ill), the only photosensitizer currently approved by the U.S. Food and Drug Administration (FDA).
1012 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. Fluoroscopy and cholangioscopy were used in conjunction to accurately place a plastic ﬁber to treat the malignant stricture. Red light photoactivation through the plastic ﬁber leads to targeted necrosis of the cancer cells charged with Photofrin. Biliary stenting of the treated stricture was conducted after PDT. After 3 months, the patient underwent a repeat PDT session per protocol, and the stents were replaced. Cholangioscopy revealed diffuse necrosis, remodeling of the stricture, and an increased diameter induced by PDT (Video 1, available online at www.giejournal.org). The patient had 3 more sessions of PDT and survived on a chemoradiation regimen for 13 months. PDT is an attractive, palliative option for patients with unresectable cholangiocarcinoma. In many studies, patients undergoing PDT showed an increased survival rate compared with conventional stenting alone. As demonstrated in Video 1,
the combination of ﬂuoroscopy and cholangioscopy appear synergistic in providing accurate and effective intraductal therapy. PDT is currently not FDA approved for palliation of cholangiocarcinoma; a randomized control trial is required and is currently under preparation (Fig 1). DISCLOSURE The following authors received research support from Gore, MI Tech, Pinnacle, and Maunakea: M. Kahaleh. In addition, the following author disclosed ﬁnancial relationships relevant to this publication: M. Kahaleh, Consultant for Boston Scientiﬁc, Xlumina, and Maunakea. All other authors disclosed no ﬁnancial relationships relevant to this publication. Janaki Patel, MD, Nada Rizk, BS, Prashant Kedia, MD, Reem Z. Sharaiha, MD, Michel Kahaleh, MD, FASGE, Division of Gastroenterology and Hepatology, Weil Cornell Medical College, Cornell University New York, New York, USA
Hybrid percutaneous-endoscopic drainage of cholelithiasis and choledocholithiasis
Figure 1. A hybrid percutaneous-ERCP approach for treatment of cholelithiasis and choledocholithiasis.
A 76-year-old woman came to us because of persistent bile leakage around her percutaneous cholecystostomy tube after multiple tube exchanges. The patient had experienced an episode of acute cholecystitis 15 months previwww.giejournal.org
ously, which was treated by placement of a percutaneous cholecystostomy tube because of signiﬁcant medical comorbidities that precluded cholecystectomy. A percutaneous cholangiogram showed multiple gallstones and Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1013