LAUSR

Biliary strictures are frequently encountered in interventional endoscopy. Their etiological diagnosis may be complicated [1]. Endoscopic ultrasound (EUS) guided biopsies, brush cytology, and wire-guided biopsies allow a diagnosis in most cases. Single-operator cholangioscopy (SOC) has radically changed the diagnostic approach, allowing visualization of the lesion, endoscopic characterization, and targeted biopsies [2]. We report the case of a 71-year-old woman with a history of endometrial adenocarcinoma, with muscular and bone recurrence 4 years after treatment. She developed a sudden jaundice without any other clinical signs. A magnetic resonance cholangiopancreatography found a circumferential parietal thickening of the main bile duct with dilatation of the intrahepatic bile ducts (▶Fig. 1). We decided to perform an EUS, which showed extensive cholangitis in the middle part of the bile duct with circumferential thickening of the bile duct mucosa. A 22 G needle biopsy was performed. Endoscopic retrograde cholangiopancreatography (ERCP) was then performed (▶Fig. 2) with SOC, which showed that the strictured area was indeed a fibrous stenosis with anarchic vascularization (▶Video 1). Biopsies were taken with forceps. Brush cytology and wire-guided biopsies were also performed. The procedure was completed with the placement of three plastic stents (one 15 cm and 8.5 Fr stent in the left bile duct; one 12 cm and 8.5 Fr stent and one 12 cm and 7 Fr stent in the right intrahepatic bile ducts). Histological examination found carcinomatous cells (mutated p53, PAX8+), which were presumed to be metastasis of gynecological origin (▶Fig. 3). The use of SOC allows a finer analysis of indeterminate biliary stenosis. The presence of aberrant vascularization seems to be correlated with the neoplastic nature of the lesion [3]. SOC therefore allows macroscopic analysis of the lesion and targeted biopsies, probably making biliary sampling less random [4, 5].