Clinical feasibility of direct peroral cholangioscopy-guided photodynamic therapy for inoperable cholangiocarcinoma performed by using an ultra-slim upper endoscope (with videos).

Background: Photodynamic therapy (PDT) has emerged as a promising palliative treatment for inoperable cholangiocarcinoma. Cholangioscopy-guided PDT can be useful for identification of tumor margins, determination of the appropriate location for placement of the diffuser, and evaluation of the patient's response to therapy.

Objective: To evaluate the feasibility of PDT under direct peroral cholangioscopy (POC) by using an ultra-slim upper endoscope in patients with inoperable cholangiocarcinoma.

Design: Prospective, observational, pilot study.

Setting: Single tertiary-care referral center.

Patients: This study involved 9 patients with inoperable extrahepatic cholangiocarcinoma.

Intervention: Photofrin II was administered intravenously 48 hours before PDT. Additional PDT was performed up to 48 hours after the initial application of therapy. A successful direct POC-guided PDT was defined as advancement of the endoscope into the distal margin of the tumor and maintenance of endoscope position until PDT was completed.

Main Outcome Measurements: The clinical feasibility, usefulness, and complications of direct POC for PDT.

Results: Seventeen sessions of direct POC for PDT were performed in 9 patients. PDT was performed successfully in 15 of 17 sessions (88.2%) and 7 of 9 patients (77.8%). Biliary drainage under direct POC, if necessary after PDT, was possible in 100% of patients (7/7). Follow-up direct POC confirmed significant tumor ablation after PDT in 5 patients. One patient reported mild skin redness; no major procedure-related complications were observed.

Limitations: Small sample size, pilot study.

Conclusion: Direct POC-guided PDT by using an ultra-slim upper endoscope seems to be both feasible and safe in select patients with inoperable extrahepatic cholangiocarcinoma.