Cholangioscopy-directed radiofrequency ablation of complex biliary cholangiocarcinoma
Bibliographic record
Abstract
A 64-year-old woman underwent a segment 5/6 liver resection in February 2016 for cholangiocarcinoma. Chemotherapy was poorly tolerated and, therefore, was stopped in August 2016. She experienced obstructive jaundice in September 2016 with CT confirmation of intrahepatic duct dilation (Fig. 1). ERCP showed a Bismuth type 1 stricture (Fig. 2), and a 10-mm uncovered metal stent (Wallflex; Boston Scientific, Natick, Mass, USA) was inserted. Subsequently, she experienced episodes of recurrent cholangitis from rapid stent occlusion with tissue ingrowth, but biopsies and brushings were negative for malignancy. Further ERCPs were performed to relieve the biliary obstruction, and another uncovered metal stent was placed within the existing metal stent.Figure 2Fluoroscopic image showing Bismuth type 1 stricture.View Large Image Figure ViewerDownload Hi-res image Download (PPT) She presented again with sepsis in March 2017, and a CT scan revealed a segment 7 liver abscess with an associated undrained liver segment and left-sided intrahepatic duct dilation (Fig. 3). She responded well initially to antibiotics and percutaneous drainage. Subsequently, in June 2017, she underwent an ERCP with Spyglass DS cholangioscopy (Boston Scientific, Natick, Mass, USA) to evaluate the intrahepatic biliary obstruction, to confirm suspected malignant involvement, and to treat this with radiofrequency ablation. ERCP and cholangioscopy showed a malignant-appearing Bismuth IIIa hilar stricture, confirmed on examination of biopsy specimens (Fig. 4; Video 1, available online at www.VideoGIE.org). The various obstructed segments were accessed (Fig. 5). Radiofrequency ablation was performed with the Habib HPB probe (EMcision, Montreal, Canada) to each obstructed segment. The immediate postablation cholangioscopic appearance of the treated tumor confirmed necrotic tissue (Fig. 6). The infected segment 7 was accessed again, and after balloon dilation, large amounts of pus were removed. Biliary drainage to each segment was maintained with three 7F gauge plastic stents.Figure 5Cholangioscopic image showing hilar obstruction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Cholangioscopic image showing changes immediately after radiofrequency ablation.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Six weeks later, repeated ERCP and cholangioscopy confirmed the efficacy of radiofrequency ablation with no macroscopic evidence of residual intraductal tumor (Fig. 7), making it possible to position three 8-mm self-expanding uncovered metal stents (Zilver; Cook Group, Bloomington, Ind, USA) into the 3 obstructed biliary segments. The patient responded positively to her treatment, inasmuch as she avoided a hospital stay for a prolonged period of time without further evidence of cholangitis and no adverse events related to the procedure itself. The outcomes for this patient are consistent with the outcomes described in the current literature.1Sofi A.A. Khan M.A. Das A. et al.Radiofrequency ablation combined with biliary stent placement versus stent placement alone for malignant biliary strictures: a systematic review and meta-analysis.Gastrointest Endosc. 2018; 87: 944-951Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar All authors disclosed no financial relationships relevant to this publication. https://www.videogie.org/cms/asset/c225d1cf-91a7-4ccc-a568-308b6b31d93e/mmc1.mp4Loading ... Download .mp4 (312.85 MB) Help with .mp4 files Video 1Initial cholangioscopic view with use of Spyglass DS system and confirmation of malignant hilar structuring. Radiofrequency ablation was then performed with use of the Habib HPB probe. Repeated immediate and delayed (at 6 weeks) cholangioscopic images showing biliary appearance after radiofrequency ablation.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".