Peroral Cholangioscopy-Guided Endoluminal Radiofrequency Ablation and Metal Stenting for the Treatment of Unresectable Perihilar Cholangiocarcinoma

Summary

This report demonstrates a stepwise ERCP-based protocol integrating peroral cholangioscopy-guided biliary mapping, targeted tissue sampling, precise endoluminal radiofrequency ablation, and self-expandable metal stent placement for the management of unresectable perihilar cholangiocarcinoma.

Abstract

Perihilar cholangiocarcinoma is frequently diagnosed at an advanced stage and is often unresectable. Malignant biliary obstruction is a major cause of morbidity and commonly requires palliative biliary drainage. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is widely used to relieve obstruction; however, tumor ingrowth and overgrowth frequently result in recurrent biliary stenosis and reduced long-term stent patency. Endoluminal radiofrequency ablation (eRFA) has emerged as an adjunctive treatment to improve local tumor control and maintain biliary drainage. Nevertheless, conventional eRFA is generally performed under fluoroscopic guidance alone, which may limit accurate delineation of tumor extent and precise energy delivery. This video article presents a single-case technical demonstration of a stepwise ERCP-based protocol integrating peroral cholangioscopy (POCS)-guided biliary mapping, targeted tissue sampling, precise eRFA, and self-expandable metal stent (SEMS) placement for unresectable perihilar cholangiocarcinoma. Direct visualization with POCS enables assessment of tumor morphology, identification of tumor boundaries, selective cannulation of involved biliary branches, and targeted biopsy acquisition. Information obtained during biliary mapping is subsequently used to define target ablation segments and guide controlled energy delivery. Following eRFA, SEMS are deployed to restore and maintain biliary drainage. This protocol provides a practical framework for visualization-guided endoscopic management of complex hilar biliary strictures and highlights key procedural steps that may improve treatment precision and procedural reproducibility in selected patients with unresectable perihilar cholangiocarcinoma.

Introduction

Cholangiocarcinoma is a highly aggressive malignancy arising from the biliary epithelium and is associated with a poor prognosis worldwide¹. Based on anatomical location, cholangiocarcinoma is classified as intrahepatic, perihilar, or distal, with perihilar cholangiocarcinoma representing the most common subtype and one of the most technically challenging forms to manage². Because most patients present with advanced disease, curative surgical resection is frequently not feasible. Consequently, relief of biliary obstruction remains a primary therapeutic objective.

Obstructive jaundice caused by....

Protocol

This study was approved by the Ethics Committee of the Second Affiliated Hospital of Guangzhou Medical University. The research tools used in this protocol are listed in the Table of Materials.

1. Informed consent

1. The patient and family were informed of the planned procedures, expected benefits, potential risks, and available alternatives. Written informed consent was obtained before treatment.

2. Pre-procedural evaluation and preparation

1. Routine laboratory testing, including complete blood count, bilirubin, albumin, and coagulation....

Results

The first ERCP session was completed successfully. Cholangiography demonstrated a hilar biliary stricture with impaired guidewire advancement. Peroral cholangioscopy (POCS) enabled direct visualization of an intraductal tumor with an irregular mucosal surface and identifiable proximal and distal margins. Selective access to the involved bile duct branches was achieved under direct visualization, allowing systematic biliary mapping. Targeted biopsy specimens were obtained without immediate complications, and histopatholog.......

Discussion

Perihilar cholangiocarcinoma is an aggressive malignancy originating from the biliary epithelium and is frequently diagnosed at an advanced stage because of its insidious onset and lack of specific early symptoms. Most patients are not candidates for curative surgical resection because of advanced local extension, vascular involvement, or poor functional reserve. Consequently, endoscopic palliation using ERCP-guided biliary drainage plays a central role in symptom control and supportive care. However, effective managemen.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Name of Material/ Equipment	Company	Catalog Number	Comments/Description
Bile duct self-expandable metal stent	Boston Scientific Corp.	RX4966	Biliary drainage
Biopsy forceps	Micro-Tech Corp.	BF10006	obtain targeted tissue samples
Catheter and guidewire	Boston Scientific Corp.	M00583100	Used for cannulation of bile duct
Duodenoscope	Olympus Corp.	TJF-260V	Used for ERCP
eRFA catheter	Boston Scientific Corp.	M00500070	Perform radiofrequency ablation on the diseased tissue
Nasobiliary duct	LeoMed Corp.	L14725D	Biliary drainage
Peroralcholangioscopy	Micro-Tech Corp.	CDS22001	Inspect the bile duct