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Background: Cholangiocarcinoma is an aggressive neoplasm that usually requires palliative biliary drainage. Photodynamic therapy (PDT) has been described as a successful adjunct treatment to malignant biliary obstruction. Aim: To describe the use of digital cholangioscope to help provide laser light during biliary PDT session using locally developed light source. Method: Patient receives intravenous photosensitizer 24 h before the procedure. It starts with a regular duodenoscopy. After identification of the major papilla and retrograde cannulation, the digital cholangioscope is introduced into the common bile duct. Then, the cholangioscopic examination helps to identify the neoplastic stricture. Under direct visualization lighting catheter is advanced through the cholangioscope. Repositioning is recommended every centimeter to cover all strictured area. At the end of the procedure, a final cholangioscopy assesses the bile duct for the immediate result and adverse events. Result: This procedure was applied in one 82-year-old male due to obstructive jaundice in the last two months. EUS and ERCP revealed a severe dilation of the common bile duct associated with choledocholithiasis. Besides, was revealed dilation of hepatic duct up to a well-circumscribed hypoechoic solid mass measuring 1.8x2 cm compressing the common hepatic duct. The mass was deemed unresectable and the patient was referred for palliative treatment with PDT. He remained asymptomatic for three months. He perished due to complications 15 months after the PDT session. Conclusion: Digital cholangioscopy-guided biliary PDT is feasible and seems safe and effective as an adjunct modality in the palliation of extrahepatic cholangiocarcinoma., Graphical Abstract Photodynamic therapy (PDT) of an extrahepatic cholangiocarcinoma using a digital cholangioscopy to deliver the laser

The incidence and prevalence of foreign body (FB) ingestion are difficult to estimate. Unlike other foreign bodies, the ingestion of a toothpick is very uncommon and carries high morbidity and mortality rates. We report a case of a 73-year-old female patient presenting mid-term epigastric pain. Abdominal ultrasound revealed a slightly dilated common bile duct (CBD) and magnetic resonance showed an irregular filling failure in distal CBD and gallstones. Endoscopic Retrograde Cholangiopancreatography revealed major papilla on the edge of a diverticulum and confirmed the distal filling failure. After sphincterotomy, a partially intact toothpick was extracted from the CBD. Neither fistulas nor perforation signs were found. Literature related to foreign bodies and toothpick ingestion was reviewed and some hypotheses to explain the reported case were created. To our knowledge, this is the first report of a toothpick lodged inside the biliary tract.

The role of preoperative biliary drainage as an adjunct in patients undergoing surgical resection for malignant biliary obstruction is controversial. The objective of the present study was to evaluate the effects of preoperative endoscopic biliary drainage and its possible association with postoperative infection in patients presenting neoplastic obstructive jaundice.The medical records of 53 patients presenting periampullary neoplasia were reviewed. In all of these patients, bile was obtained intraoperatively by puncture. Among the 53 patients, 14 had been submitted to preoperative endoscopic drainage (Group I) and 39 had undergone surgery without decompression (Group II). For statistical analysis, the level of significance was set at 5%.Bile culture was positive in 13 (92.8%) of the patients in Group I, a significantly higher incidence than that observed in group II, in which 16 (41%) of the patients presented positive cultures (p=0.001). There was no significant difference in general postoperative morbidity between groups (64.2% for group I vs. 46% for group II) or mortality (0% vs. 7.6%, respectively). When infective complications (cholangitis, pneumonia, wall infection) were analyzed separately, a higher incidence, although without significance, was found in Group I than in Group II (50% vs. 28.2%, respectively; p=0.1913).The presence of an endoscopic biliary drain provokes bacterial colonization, possibly due to the combination of residual cholestasis and duodenal reflux to the bile duct, raising concerns about the possible appearance of infective complications during the postoperative period.