The second patient was a 68-year-old female referred to the Department of Interventional Radiology, Beijing Chaoyang Hospital (Beijing, China) by an endoscopist following failed ERCP. The patient refused surgery. Adenocarcinoma of the ampulla was confirmed by biopsy. PTBS was performed to resolve obstructive jaundice. The major papilla was located inside a large juxtapapillary diverticulum during the procedure (Figs. 1-2). The biliary stent was implanted successfully to cover the stenotic bile duct, with perfect cholangiographic results (Fig. 3). The patient experienced an uneventful post-procedural outcome. CT performed 4 days after PTBS showed the tumor surrounding the intradiverticular papilla (Fig. 4).
Written informed consent was obtained prior to the interventional procedure in the two patients. PTBD was performed using right lobe punctures under fluoroscopic guidance in each patient. Access to the biliary tree was gained using standard interventional techniques and a 7F sheath was inserted to facilitate the following procedure. A 5F, 40-cm angled tip catheter (Kumpe; William Cook Europe ApS, Bjaeverskov, Denmark) was used in conjunction with a 0.035-inch hydrophilic guidewire (Radiofocus M; Terumo Corporation, Tokyo, Japan) to advance through the papillary stricture into the duodenum. The hydrophilic guidewire was exchanged for a 0.035-inch stiff guidewire (Amplatz Super Stiff; Boston Scientific, Natick, MA, USA). A 0.8x4.0-cm balloon (William Cook Eurpoe ApS) was advanced over the guidewire towards the duodenum to dilate the stricture and papilla orifice. Finally, a self-expanding metallic stent (Zilver; William Cook Eurpoe ApS) was inserted alongside the guidewire and through the papilla into the duodenum.
PTBS was performed successfully without procedure-associated complications in the two patients. The patients remained well at the six-month post-procedure follow-up visit.