Volume 3, Issue 5, Pages (May 2018)

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Volume 3, Issue 5, Pages 166-168 (May 2018) Interventional cholangioscopy and management of hepatic cystic echinococcosis complicated by cystobiliary fistula Matthew R. Krafft, MD, Paul Cassis, MD, William Hsueh, MD, Jeffrey M. Quedado, PharmD, John Nasr, MD VideoGIE Volume 3, Issue 5, Pages 166-168 (May 2018) DOI: 10.1016/j.vgie.2018.02.007 Copyright © 2018 American Society for Gastrointestinal Endoscopy Terms and Conditions

Figure 1 A, CT view with intravenous contrast material showing a giant multiseptated cyst, 10 cm × 9 cm × 9 cm. Cyst septations produce a “wheellike” appearance. Cyst morphology is consistent with WHO-IWGE on Echinococcus classification type CE2 or Gharbi classification type III (active stage). B, Ultrasonographic view of liver showing a “rosette-like” pattern of daughter cysts contained along the inferior margin of the echinococcal cyst. C, CT view with intravenous contrast material demonstrating a unilocular homogenous cyst with a floating laminated membrane along the superior margin (dimensions: 13 cm × 12 cm × 14 cm). Cyst morphology is most consistent with WHO-IWGE classification type CE3a or Gharbi classification type II (transitional stage). D, Graph of serum absolute eosinophil count and serum total bilirubin plotted over time with markers of medical therapy and endoscopic intervention. Time 0 months represents time of diagnosis. E, CT view with intravenous contrast material 3 weeks after intervention with ERCP and cholangioscopy. Interim decrease in the size of the echinococcal cyst has occurred (new dimensions: 9 cm × 11 cm × 10 cm). Small foci of air are seen within the echinococcal cyst. The cyst most likely remains WHO-IWGE classification type CE3a or Gharbi classification type II (transitional stage). WHO-IWGE, World Health Organization Informal Working Group Classification. VideoGIE 2018 3, 166-168DOI: (10.1016/j.vgie.2018.02.007) Copyright © 2018 American Society for Gastrointestinal Endoscopy Terms and Conditions

Figure 2 A, Occlusion cholangiogram during ERCP demonstrating cystobiliary fistulas arising from the right and left hepatic ducts. The giant echinococcal cyst is filled with contrast dye. B, Expulsion of brood capsules from the common bile duct, with use of extraction balloon catheter, after biliary endoscopic sphincterotomy. C, Fluoroscopic visualization of the biopsy forceps (SpyBite) located within the echinococcal cyst. The cholangioscope (SpyScope DS Catheter) is positioned immediately distal to the cystobiliary fistula. The biopsy forceps are being deployed across the cystobiliary fistula and into the echinococcal cyst, to mechanically disrupt the cyst contents (ie, germinal membrane, brood capsules). VideoGIE 2018 3, 166-168DOI: (10.1016/j.vgie.2018.02.007) Copyright © 2018 American Society for Gastrointestinal Endoscopy Terms and Conditions