Endobiliary radiofrequency ablation of an intraductal vessel in a patient with surgically altered anatomy

**Background:** Hemobilia is bleeding into the biliary tract, most commonly caused by traumatic, malignant, or iatrogenic etiologies. It presents significant diagnostic and management challenges. Endobiliary radiofrequency ablation (RFA) has been previously described as a salvage treatment for hemobilia, but its use in patients with surgically altered anatomy has not been well documented. This case report describes the successful application of endobiliary RFA for refractory hemobilia in a patient with prior Whipple procedure.

**Methods:** A 49-year-old man with a history of chronic pancreatitis following Whipple procedure presented with hematemesis and hematochezia. Initial enteroscopy revealed blood throughout the afferent and efferent limbs with a clot at the hepaticojejunostomy anastomosis. Two subsequent endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed to remove blood clots and place biliary stents. Due to ongoing bleeding, the patient underwent empiric embolization of the left and right hepatic arteries. When bleeding persisted with associated hemodynamic instability, a multidisciplinary discussion led to the decision to attempt salvage endobiliary RFA. An ERCP was performed using a standard adult colonoscope. After biliary cannulation, a cholangioscope (SpyScope DS II; Boston Scientific) was advanced through the colonoscope. Examination of the left hepatic duct revealed an intraductal vessel with surrounding bloody material. The RFA catheter (Habib; Boston Scientific) could not be advanced through the colonoscope due to its length, requiring exchange for a therapeutic gastroscope. The RFA catheter was then advanced over a guidewire to the level of the vessel. Two applications of RFA were performed at Effect 8, Power 10 watts, for 90 seconds each. Repeat cholangioscopy showed only partial ablation, so two additional RFA applications were required before sufficient ablation was achieved. Bilateral 10 Fr biliary stents were then placed.

**Key Results:** The endobiliary RFA successfully achieved ablation of the intraductal visible vessel. The patient had no further episodes of bleeding during 14 months of follow-up. The procedure required four total RFA applications (two initial applications plus two additional applications after partial ablation was noted on repeat cholangioscopy). A technical challenge was encountered: the RFA catheter could not be advanced through the standard adult colonoscope due to its length, necessitating an intraprocedural scope exchange to a therapeutic gastroscope.

**Clinical Implications:** This case demonstrates that endobiliary RFA can be an effective salvage treatment for refractory hemobilia, even in patients with surgically altered anatomy such as those who have undergone Whipple procedure. The successful outcome with no bleeding recurrence over 14 months suggests durable hemostasis. The case also highlights important technical considerations: the need for appropriate endoscope selection to accommodate RFA catheter length, and the potential need for multiple RFA applications to achieve complete vessel ablation. Multidisciplinary discussion and a stepwise approach (from endoscopic clot removal and stenting to embolization to RFA) are important in managing this challenging condition.