Ravi Shah, MD1, Neal Mehta, MD1, Feng Li, MD1, Sunguk Jang, MD1, Ji Yoon Yoon, BMBCh1, Gautam Mankaney, MD1, Matthew F. Kalady, MD1, James M. Church, MBChB1, Carol A. Burke, MD, FACG1, R. Matthew Walsh, MD1, Amit Bhatt, MD2
1Cleveland Clinic Foundation, Cleveland, OH; 2Cleveland Clinic, Cleveland, OH
Introduction: Duodenal cancer is the second most common malignancy in FAP patients, and advanced polyposis often requires duodenal resection. Post-duodenectomy FAP patients are at risk of developing polyps in the post-anastomotic jejunum. We present a challenging case of a post-duodenectomy FAP patient who developed adenomatous polyp at the biliojejunal anastomosis and bile duct.
Case Description/Methods: A 36 year-old female with FAP, status-post proctocolectomy, pancreas-sparing duodenectomy for Spiegelman stage IV polyposis was found to have polyposis in the jejunum on surveillance capsule endoscopy. Push-enteroscopy revealed polyposis in the jejunum with a 15mm polyp involving the biliojejunal anastomosis (Image 1). Given that this polyp was non-lifting, it was removed with hybrid endoscopic submucosal dissection (ESD) (Image 2). After polyp removal, there was suspicion the polyp extended into the distal common bile duct (CBD) which was confirmed with biopsies revealing low-grade dysplastic adenoma. After a multidisciplinary discussion, cholangioscopy with Habib EndoHPB radiofrequency ablation (RFA) (Boston Scientific, Marlborough, MA, USA) was planned (Image 3). The adenomatous tissue extended from the distal CBD to the proximal common hepatic duct (CHD) which was confirmed by biopsies. Biliary RFA treatment was inadequate evidenced by poor tissue response noted on cholangioscopy and repeat positive biopsies.We theorized that this was due to poor tissue apposition with the thin RFA catheter as there was no stricture. Given the patient’s young age, extent of bile duct involvement, and poor tissue response to RFA, we determined that a completion Whipple surgery would be the best long-term option.
Discussion: We present a unique case of a post-duodenectomy FAP patient with adenomatous polyp extending from the biliojejunal anastomosis to the proximal hepatic duct. We were able to remove the polyp at the biliojejunal anastomosis with hybrid ESD, but the biliary adenomatous tissue was not adequately treated by biliary RFA. The thin RFA catheter had poor contact on the bile duct wall as there was no stricture. If a balloon RFA biliary catheter existed that could provide better tissue contact with a normal diameter bile duct, maybe this could have been treated endoscopically. This case highlights the importance of multidisciplinary management of complex polyposis in FAP patients.
Citation: Ravi Shah, MD; Neal Mehta, MD; Feng Li, MD; Sunguk Jang, MD; Ji Yoon Yoon, BMBCh; Gautam Mankaney, MD; Matthew F. Kalady, MD; James M. Church, MBChB; Carol A. Burke, MD, FACG; R. Matthew Walsh, MD; Amit Bhatt, MD. P1486 - ADENOMATOUS POLYP OF THE BILIOJEJUNAL ANASTOMOSIS AND BILE DUCT IN A FAMILIAL ADENOMATOUS POLYPOSIS (FAP) PATIENT: A MULTIDISCIPLINARY APPROACH TO A CLINICAL DILEMMA. Program No. P1486. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.